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
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”.
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.
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.