If I think certain words in my policy mean something different from what my insurance company says they mean, how do we resolve it?
Total Comments: 8
Posted: Wed Dec 02, 2009 12:25 pm Post Subject:
You won't ... most policys have definition in them that tell you what those terms 'mean' as they relate to the policy..
What word/term are you talking about and what do you think it means, and your carrier?
Posted: Wed Dec 02, 2009 10:18 pm Post Subject:
waht are the specific terms in question? Are they defined in the policy wording as Lori mentions?
If they are, then that is the definition that will be used, regardless of what you think the terms should mean.
If they are not defined then they MAY be open for debate.
Posted: Thu Dec 03, 2009 12:58 am Post Subject:
Even terms such as, "you", "we", "us" "our" are defined, (usually in the front-and if any changes, in the front section of each coverage) in all policys I've ever read..
Posted: Thu Dec 03, 2009 05:38 am Post Subject:
Contrary to what Lori says, there is a principle in contract law (especially so in insurance contracts) known as "adhesion." It deals with, specifically, ambiguities in a contract.
An ambiguity arises when two persons, giving ordinary meaning to the words they read, have two entirely opposite understandings of what they have read. If it comes down to a dispute in court over you read a clause in a way that says "the insurer must pay," and when the insurer reads it, it says, "We don't pay at all," then the judge/jury will have to decide.
If the decision is, "Yes, this is ambiguous," the rule of law says that the provision must either be read on favor of the party that did not write the words in questions (insured), or the provision eliminated from consideration as a reason to not pay a claim, forcing the insurer to look for other grounds to not pay a claim.
Having said that, Lori is right when she says there will be a list of definitions in the policy to help guide everyone in their understanding of the contract. It would be very helpful if you post the contract language you are concerned about, so we can help you understand it, as Lori and Heidrek have posted.
Posted: Thu Dec 03, 2009 06:23 am Post Subject:
Posted: 30 Sep 2009 05:58 Post subject: Kids insurance!!
I took my kids to the pediatrician where they received vaccinations, but one of those vaccines was not covered by my insurance. Am I responsible to pay? Shouldn't the physician's office have told me that it was not covered?
This was posted by the OP back on September 30th. I would assume he is still having a problem with this claim.
Posted: Thu Dec 03, 2009 06:52 am Post Subject:
policys I've ever read
Read a policy. We don't need to read no stinking policy.
Posted: Thu Dec 03, 2009 07:14 am Post Subject:
"One of those vaccines was not covered by my insurance. Am I responsible t pay? Shouldn't the physician's office have told me that it was not covered?"
Certainly clears the air a bit!
Yes, you would be responsible to pay. I'm sure you signed an agreement to that effect with the doctor. Is the doctor's office supposed to know everything that is or is not covered by your insurance? No. Are they required to call the insurer for authorization? Perhaps. Did they? Don't know. If they didn't, and they don't have to, there is no recourse against the doctor's office.
What was the vaccination for? Almost all routine vaccinations for children are covered. Perhaps the doctor's office inadvertently submitted the wrong claim code. Have you inquired about that possibility?
Still a few loose ends to clear up.
Posted: Thu Dec 03, 2009 08:53 am Post Subject:
how do we resolve it?
If the words are commonly used terms in the insurance industry, then you'll find the right explanation in an insurance terminology site. If they're not the common terms, then you may discuss with your agent or carrier rep. demanding a proper explanation for the same.
Posted: Wed Dec 02, 2009 12:25 pm Post Subject:
You won't ... most policys have definition in them that tell you what those terms 'mean' as they relate to the policy..
What word/term are you talking about and what do you think it means, and your carrier?
Posted: Wed Dec 02, 2009 10:18 pm Post Subject:
waht are the specific terms in question? Are they defined in the policy wording as Lori mentions?
If they are, then that is the definition that will be used, regardless of what you think the terms should mean.
If they are not defined then they MAY be open for debate.
Posted: Thu Dec 03, 2009 12:58 am Post Subject:
Even terms such as, "you", "we", "us" "our" are defined, (usually in the front-and if any changes, in the front section of each coverage) in all policys I've ever read..
Posted: Thu Dec 03, 2009 05:38 am Post Subject:
Contrary to what Lori says, there is a principle in contract law (especially so in insurance contracts) known as "adhesion." It deals with, specifically, ambiguities in a contract.
An ambiguity arises when two persons, giving ordinary meaning to the words they read, have two entirely opposite understandings of what they have read. If it comes down to a dispute in court over you read a clause in a way that says "the insurer must pay," and when the insurer reads it, it says, "We don't pay at all," then the judge/jury will have to decide.
If the decision is, "Yes, this is ambiguous," the rule of law says that the provision must either be read on favor of the party that did not write the words in questions (insured), or the provision eliminated from consideration as a reason to not pay a claim, forcing the insurer to look for other grounds to not pay a claim.
Having said that, Lori is right when she says there will be a list of definitions in the policy to help guide everyone in their understanding of the contract. It would be very helpful if you post the contract language you are concerned about, so we can help you understand it, as Lori and Heidrek have posted.
Posted: Thu Dec 03, 2009 06:23 am Post Subject:
Posted: 30 Sep 2009 05:58 Post subject: Kids insurance!!
--------------------------------------------------------------------------------
Hi,
I took my kids to the pediatrician where they received vaccinations, but one of those vaccines was not covered by my insurance. Am I responsible to pay? Shouldn't the physician's office have told me that it was not covered?
This was posted by the OP back on September 30th. I would assume he is still having a problem with this claim.
Posted: Thu Dec 03, 2009 06:52 am Post Subject:
policys I've ever read
Read a policy. We don't need to read no stinking policy.
Posted: Thu Dec 03, 2009 07:14 am Post Subject:
"One of those vaccines was not covered by my insurance. Am I responsible t pay? Shouldn't the physician's office have told me that it was not covered?"
Certainly clears the air a bit!
Yes, you would be responsible to pay. I'm sure you signed an agreement to that effect with the doctor. Is the doctor's office supposed to know everything that is or is not covered by your insurance? No. Are they required to call the insurer for authorization? Perhaps. Did they? Don't know. If they didn't, and they don't have to, there is no recourse against the doctor's office.
What was the vaccination for? Almost all routine vaccinations for children are covered. Perhaps the doctor's office inadvertently submitted the wrong claim code. Have you inquired about that possibility?
Still a few loose ends to clear up.
Posted: Thu Dec 03, 2009 08:53 am Post Subject:
how do we resolve it?
If the words are commonly used terms in the insurance industry, then you'll find the right explanation in an insurance terminology site. If they're not the common terms, then you may discuss with your agent or carrier rep. demanding a proper explanation for the same.
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