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Sometimes, an insurance company denies a claim from the insurance holder on account of wrong assessment of his claim. This may lead the insured to suffer:

1. Financial damages in the sense that he may fail to get the right treatment because of the lack of funds.

2. Lapse of time in the sense that the insured may lose reasonable time for the proper treatment, and his/her medical condition may become severer.

The only way out is to do the standard reversed for ignoring medical evidence and improper denial

Illustration

A person has been diagnosed with cancer, and the doctor decides to release them on “as tolerated” basis. This signifies that the said person may not be able to complete his working hours due to medical issues. Moving further, the insurance company denied his insurance claim due to either or both
of the following situations;

1. It overlooked the term “partial disability” and mentioned that the person was able to work 100%.

2. In a bid to back its statement, the company provides proof of him working on part-time basis elsewhere.

In such situations, the court may give priority to the medical history of the insured, before it considers any other pieces of evidence no matter how conclusive they are.

 

The Lawsuit: Ms. Marcin V Reliance Standard Life Insurance Company

The lawsuit we’re referring to was held in the district court of Columbia, United States. It was about the unreasonable consideration made by Reliance Standard Life Insurance Company of insured’s health.

According to the plaintiff, Ms. Jill Marcin, she was suffering from multiple health issues such as anemia, kidney cancer, and others. She was released by her doctors on “as tolerated” basis, which means, she couldn’t complete 40 working hours every week as normal employees do. This medical evidence amounts to “partial disability”.bfhd

Instead of considering her partial disability, the defendant – Reliance Standard Life Insurance Company – treated it as “total disability” which had an entirely different meaning (the person may not be able to work at all and is entitled to benefits).

Based on the wrong assumption, the company concluded that as Jill Marcin was working on a part-time basis, she could work 100%.
Therefore, her claim for long-term benefits was denied because she wasn’t disabled.

To support the decision, the defendant referred to two instances when the doctor had reviewed her medical condition as “feeling better”. Yes, there were a few instances when her doctor noted that she was “feeling better”, but her overall health was generally on the decline. Ms. Marcin’s absence from work increased with time, as her overall health was depleting.

 

What Court Considered

The district court ruled its decision in favor of the plaintiff and held the insurance company liable for payment of all the dues. Later, the U.S. Court of Appeals for the District of Columbia affirmed and given the same judgment.

RSL Insurance was unreasonable in determining that she was completely capable of doing 100% work. The medical history evidently showed that she hadn’t managed to complete a 40-hour week.dsvfdb

The decision made by RSL did not acknowledge the fact that her work showed she never worked full time. It was evident from the record that her work hours reduced sharply.

The RSL could not address the fact that Ms. Marcin’s health condition had gone from “mild” to “extreme”.

RSL relied on paid medical reviews. The unreliability of the reviews is based on the fact that the examination and the medical history were not linked.

One review was deemed unreliable because it wasn’t conclusive enough.…

Insurance is supposed to help us and protect us when we are in a problem. However, this is not always the case as problems are bound to arise during the period of processing the claim. It is quite unfortunate that nowadays, there are many cases in most of our courts regarding the insurance claims. What does this tell you? Well, it serves as a warning that never should you take matters related to insurance claim lightly. Whenever there is a problem with your claim, it is always good to ensure that you get the help of experts to successively get out of your problem. Here are important tips on how to deal with any problem as far life insurance policy is concerned.

Extensive research

To know your policy back and forth, you will need to gather as much information about it as possible. This, therefore, means that you will need to read all the guidelines and the fine print that you are given when signing the agreement. It is good that you know what you should and what to avoid if you do want to spoil your insurance claim. Being knowledgeable is important as it will help you during the communication process with your insurance company. After all, information is power.

Consult your lawyer

Another important thing that you should do to avoid the unnecessary problem you will need to find a good life Insurance Lawyer. Sometimes you might find that you are on the right, but the insurance company still refuses to honor the agreement. In such like situations, a life insurance lawyer will be the right choice. A professional lawyer will add a lot of weight and ensure that you can get the justice that you deserve.

Do not take anything for granted

Some people tend to assume that the insurance company is always on the right. That is a very ignorant perception. If you claim is delayed or even denied, and the reasons are not clear, you will need to find a good lawyer. There are many people whose claims have been denied, and after they had taken the matter to the court, they were able to win. So assuming that the insurance company is always on the right is something that you should desist from.

Keep track of everything

This is also very important. In fact, it is one of the reasons why problems arise. If the insurance company realizes that you have not been keeping track of all the necessary steps, the chances are that might want to exploit you in the way or the other. So make sure that you have all the papers involved in the entire process documented. In addition to that, you need to understand that keeping records is essential as far as insurance policies are concerned.

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