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Critical illness insurance is a specialized type of insurance that pays out if two things occur: first, you are diagnosed with an illness that is listed in the policy; and second, you survive for at least the time period specified in the policy.
Critical illness insurance can help ease financial burdens while recovering from a serious medical issue. Many professionals and other self employed people purchase an individual policy through an agent or broker. Some workplace group benefit plans also provide critical illness coverage.
Sometimes insurance companies refuse to pay out on legitimate critical illness claims. If that has happened to you or a loved one, it is important to consult with a critical illness insurance lawyer as soon as possible, as there are strict time limits that must be adhered to.
There are several reasons why an insurer might refuse to pay a claim.
The most common is when the diagnosis does not meet the policy definition.
Covered illnesses and diseases often include cancer, Parkinson’s, AIDS, Lou Gehrig’s Disease (ALS), heart attack, stroke, organ transplants, kidney failure, paralysis, and blindness. However, not all types and variations of these medical conditions will result in payment. The insurance policy will provide additional details for what is covered. For example, the policy might define heart attack as follows:
Heart attack (acute myocardial infarction) means a definite diagnosis of the death of heart muscle due to obstruction of blood flow, that results in a rise and fall of biochemical cardiac markers to levels considered diagnostic of acute myocardial infarction, with at least one of the following:
The diagnosis of heart attack (acute myocardial infarction) must be made by a specialist. The insured person must survive for 30 days following the date of diagnosis.
No benefit will be payable under this condition for: elevated biochemical cardiac markers as a result of an intra arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves, or ECG changes suggesting a prior myocardial infarction, which do not meet the heart attack definition as described above.
This definition is very technical, and contains an exclusion which is equally technical. Sometimes there is a genuine dispute in the medical evidence regarding whether the policy requirements are met.
Critical illness claims may also be denied if the insured person does not meet the survival period. In the heart attack example above, the survival period is 30 days. If death occurs within 30 days of the heart attack, the insurer is not required to pay.
Another common reason critical insurance claims are denied relates to the application process. If there was a failure to disclose part or all of your medical history, this could amount to a material misrepresentation, or in some cases an allegation of fraud. If the misrepresentation was not fraudulent, there are several legal arguments to challenge the denial.
If your critical illness claim has been denied, you have the right to dispute the denial. You also have the right to consult with a critical illness insurance lawyer, at no cost to you. Before consulting a lawyer, you should have the following ready:
Michael Jordan will then be able to provide you with a preliminary opinion. If Michael is of the opinion the insurance company may have gotten it wrong, most cases can proceed on a contingency fee basis; that is, a “no win, no fee” arrangement where the legal fees are a fixed percentage of the total recovery, usually 30%. Contingency fee retainer agreements are governed by the Law Society of Ontario.
To learn more, contact Michael Jordan, an insurance lawyer with more than 18 years experience resolving all types of insurance disputes, including denied critical illness insurance claims. He is a founding partner of the Bay Street litigation firm Jordan Honickman Barristers, serving clients across all of Ontario.
Michael Jordan
Jordan Honickman Barristers
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