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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.
QUADRIPLEGIA
$1,950,000
Our client sustained serious injuries in a motor vehicle accident. She advanced claims against her insurance company for income replacement benefits, medical expenses, and cost of care. The claim settled for close to $2 Million dollars.
BIPOLAR DISORDER
$575,000
Our client was a successful business person. When his long term disability claim was denied, he retained Michael Jordan to take legal action against the LTD insurer. Expert medical evidence that was instrumental in resolving the case.
DEPRESSION
$400,000
Our client was unable to work due to debilitating depression and anxiety. The disability insurer denied the claim, but when faced with litigation, a settlement was achieved allowing the client to focus on his recovery.
CANCER
$400,000
Our client was diagnosed with life threatening cancer, which resulted in a severe psychiatric response. The claim was denied based on an exclusion in the policy. The exclusion, however, was poorly drafted and the case quickly settled.
LONG COVID
$275,000
Brain fog, fatigue, and inability to focus and concentrate were the main symptoms. The LTD insurer denied the claim due to lack of "objective medical evidence", even though there was no requirement in the policy to provide objective evidence, and the nature of the impairments were inherently subjective. The case settled after litigation was commenced.
PSYCHOSIS
$270,000
The claim was denied because our client was not participating in appropriate treatment, but his mistaken belief that he did not need treatment was a symptom of his disability. An expert psychiatrist was retained to provide opinion evidence that the failure to participate in treatment was a symptom of the underlying illness. The case quickly settled.
CANCER
$267,000
Our client had surgery to remove the tumour, but was left with severe chronic pain and anxiety. An opinion from an expert oncologist supported disability and a fair settlement soon followed.
VERTIGO AND NAUSEA
$255,000
The long term disability insurer did not believe our client’s self reported symptoms. During the litigation, extensive medical records and reports were obtained that supported disability.
CHRONIC FATIGUE
$250,000
The claim was denied because there was no medical explanation for the sudden onset of chronic fatigue syndrome. Two expert reports were secured, and the case settled at mediation.
ANXIETY
$250,000
Our client suffered from severe anxiety that made work impossible. Despite this, her LTD claim was denied. It settled shortly after a lawsuit was commenced.
CHRONIC PAIN
$250,000
Our client was involved in a motor vehicle accident many years ago. He continued to suffer chronic pain, but the LTD insurer denied his claim. Expert opinion evidence helped secure the settlement.
MIGRAINE HEADACHES
$240,000
The insurance company denied the claim after the two year “own occupation” test of disability changed to “any occupation”. Evidence was secured that the client could not work in any job, and the case resolved.
Previous results are not necessarily indicative of future results. Contact Michael Jordan, long term disability lawyer, for an assessment of your claim.
Michael Jordan
Jordan Honickman Barristers
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