My uncle insurance failed to claim

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PostPosted: Mon Apr 20, 2009 10:22 am   Post subject: My uncle insurance failed to claim  

Hi, all nice members here, i would like to seek your advices on my uncle insurance case.



My uncle bought a health insurance on past 10 years ago, and now he passed away due to lung cancer. My family are trying to get the insurance claims for his wife and daughter, but then the insurance company has rejected our claims after 1 year of negotiation.



The reason for the insurance company rejects is they claims that my uncle is havng lung cancer before purchase the insurance 10 years ago. We are really in doubts cos during that time, my uncle bought this insurance from one of his friend, insurance agent. During that time, according to my uncle's wife, my uncle did get the appointed doctor medical report approved before purchasing.



Now after a long year of paying the premium, and finally he passed away, the insurance company did not even pay us single cents, nor refuse to pay back this 10 years funds that my uncle has paid.



We really need help on seeking a way to claims back the money. Why the insurance company can simply come out a reason to reject our claims, is there any rules sue back them?



Thanks for your time on our issues here.

eddielkk
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PostPosted: Mon Apr 20, 2009 11:06 am   Post subject:   

The insurer can deny coverage based on misrepresentation of facts by the insured. Was he receiving treatment at the time of purchasing the policy? Now if you can prove that he wasn't under medication during the time of buying the policy, the insurer is acting under bad faith.

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PostPosted: Mon Apr 20, 2009 11:49 am   Post subject:   

If he was diag. with lung cancer or had any treatments for it PRIOR to buying the policy then it was a pre-exsisting condition and they can deny it...he had to have filled out an application that would've asked very specfic health questions...ask for a copy of that app...what was the date that he first went to the doc for this? what was the date he purchased the policy? doesn't matter if it was a different doc than the one he ultimately saw...the ins company will find out about another doc he treated with...no ins company denys claims for mis=rep without a solid reason...check the dates again, and make sure they are not correct ..



Has the carrier paid for ANY health claims at all? Other than related to lung cancer? If they have then they won't have to refund the premium he has paid, however if no claims have been paid at all and they are denying this based on material mis-rep then they will refund the premium..



If you can't get anywhere and still are 100% sure he completed this app honestly (ask for a copy of the app from the agent)...then file a complaint with your states dept of ins.



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PostPosted: Mon Apr 20, 2009 12:48 pm   Post subject:   

I think if the insured person had given the status of the health history as 'not suffering from the lung cancer' & if still the insurer proves that the insured person was having this disease prior to purchasing the policy then surely they can deny the policy benefit.



But if the insured person had gone through the medical check-up prior to the policy purchase and had declared fit by the medical officer of the third party agency and if you have the docs pertaining then surely you will get the claim for it.But you need to lead a battle in a court in order to prove this.



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PostPosted: Mon Apr 20, 2009 4:51 pm   Post subject:   

Well, this insurance has been purchase 10 years before, and my uncle already passed away. According to his wife, he did get the appointed doctor from insurance company approval medical documents prior purchase the insurance.



But now the insurance company claims that the policy that he bought during the time did not attached with those documents, and said that my uncle is purposely hiding his sick info from them. I feel fishy here as to get to policy approved, they should have the full documents before proceding, am i right? We did points out this to them, and they said this must be the mistake that the insurance agents who did this policy before.



Now the insurance agents is no more working with them, and according to their company policy, since the documents is not completes and they suspect that my uncle in hiding his sick with them, where they said that they investigate and find out my uncle is having lung cancer 10 years ago, and they have never show us the proof of their investigation, hence the claims is not approved.



Dont you all thinks that this is their company internal fault for didn't have full documents but still proceed with the policy, and now just finding excuse to not paying?

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PostPosted: Tue Apr 21, 2009 4:22 am   Post subject:   

Hey Eddie, the medical history questioner of health policy would explicitly ask if you have/had any form of cancer or cancerous growth in the past or are being treated for it now. But typically they would conduct any test to determine the same. The tests in medical underwriting consist of- electrocardiogarm, HIV test, blood tests to determine sugar and abnormality in urine and the like. An individual would qualify for the health coverage if he satisfies these tests.



Now the problem lies with whether or not your uncle was diagnosed with the lung cancer before buying the policy. If he was diagnosed before but mentioned otherwise in the questioner the insurer can deny the claim based on misrepresentation of facts.



Has the insurer paid out any claim towards the treatment of it in the past? If so then they might not be able to deny the claim now.



Thanks,

Rupert

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PostPosted: Tue Apr 21, 2009 5:35 am   Post subject:   

Hi, Rupert,



I understand that the insurer will have to carry out all the necessary health tests by their approved doctor before approving the health insurance. Now this is the problems, since they have already approved and started the policy plan, but now why after 10 years when we claimed then only they say they find out that my uncle is having lung cancer before and the disapproved the claims?



Well, my uncle did not claims any treatment with them in the past. Since we won't know whether my uncle was diagnosed of lung cancer or not befoer the policy, cos there is no proof now. I wonder how the insurer still able to investigate it out and said that they find out my lung lie to them? From what proof their findings?



Now, we are thinking to pass to lawyer to see whether we can sue them or not. How you all think?

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PostPosted: Tue Apr 21, 2009 11:05 am   Post subject:   

It seem like a complicated case here. No one is able to know the case happend 10 years ago. The main problems now is whether your uncle really lie to the insurance company when he bought the policy, and i also don't think that the insurance company is able to get the answer since your uncle already pass away.



If the insurance company have a proof to show that your uncle is hiding his sick from them. Then i think you have to check the dates of the policy purchase. They might find out that your uncle has been diagnosed for the lung cancer in other hospital record that showing earlier than policy bought.



If you sue them in this way, you will definately lose. The important things now is find out the policy date, and then check with your aunt the medical report date that showing your uncle is having lung cancer, see which one is earlier.

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PostPosted: Tue Apr 21, 2009 2:23 pm   Post subject:   

Hi eddielkk..



Quote:
Well, my uncle did not claims any treatment with them in the past.


Well, then as Lori has said the premiums should be refunded.

Quote:
But now the insurance company claims that the policy that he bought during the time did not attached with those documents, and said that my uncle is purposely hiding his sick info from them.


Did you guys need to attach any other document pertaining to his health while filing the claim?



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PostPosted: Wed May 06, 2009 1:39 am   Post subject:   

so even the insurance compay they appointed their doctor and approval medical documents prior purchase about this insurance. that's their own problem even your uncle really have that cancer before the purchase.

you can consult with some lawyer and claim with the insurance company again. good luck.



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PostPosted: Wed May 06, 2009 10:06 am   Post subject:   

Quote:
that's their own problem even your uncle really have that cancer before the purchase
no it's not if he knew or suspected this and did'nt declare so in the application.


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PostPosted: Thu May 07, 2009 2:33 am   Post subject:   

well. since that insurance company have reviewed his uncle's health by the assigned doctor . that's means they admitted the uncle is under their requirements so the uncle insured there. if the uncle really was sick from then but the company still insured him that means they cheat his uncle.

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PostPosted: Thu May 07, 2009 9:59 am   Post subject:   

Hi Tohawk, you may read Rupert's response above. The medical underwriting doesn't include tests for cancer. If OPs uncle was diagnosed with cancer at the time of purchasing the policy but withheld the information knowingly, then itÂ’s the uncle who has cheated the insurance company and not the opposite.



Quote:
Well, my uncle did not claims any treatment with them in the past.




Eddie, if during all these years of treatment your uncle never actually had turned to his insurer for compensation then what the family members are trying to claim now? Confused The health insurance would pay only for medical expenses and it wouldn't pay out any death benefit.
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PostPosted: Thu May 07, 2009 10:41 am   Post subject:   

Quote:
well. since that insurance company have reviewed his uncle's health by the assigned doctor
They don't do a complete medical work up to catch each and every ailment...the OP does say,
Quote:
my uncle is havng lung cancer before purchase the insurance 10 years ago
Doesn't matter what the doc report said, if he knew he had cancer and did not disclose this fact of the application for insurance then this is material mis-rep, and will be denied, they should also receive all their premiums back (in the USA anyway)


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PostPosted: Thu May 07, 2009 11:00 am   Post subject:   

Nothing in this thread makes any sense to me.



If I understand the facts, someone bought health insurance over 10 years ago and may or may not have had lung cancer at that time. He died a year ago and the health insurer isn't paying claims. What about all of the years before that? Were there 9 years of treatment for which they did pay claims? The facts as written don't pass the smell test.



Quote:
Now if you can prove that he wasn't under medication during the time of buying the policy, the insurer is acting under bad faith.




Lots of people can have health issues and not be taking medication. This is not relevant.



Quote:
But if the insured person had gone through the medical check-up prior to the policy purchase and had declared fit by the medical officer of the third party agency and if you have the docs pertaining then surely you will get the claim for it.




Incorrect, as usual, Amit. First of all, one doesn't get "declared fit by the medical officer of the third party agency". When testing is done, it is done by a third party, but they don't declare someone fit or unfit. They simply send the results to the insurance company. Secondly, the insurance company doesn't declare someone fit. They approve a policy. They are approving the policy based upon medical testing AND the information that the insured gave. If the insured doesn't disclose material information, a health insurance policy won't be paid. It is highly doubtful that the insurance company did any testing at all.



Quote:
The tests in medical underwriting consist of- electrocardiogarm, HIV test, blood tests to determine sugar and abnormality in urine and the like. An individual would qualify for the health coverage if he satisfies these tests.




Rupert, I don't do a lot of health insurance, but I've never seen anyone have to do any of this for health insurance. They do it for life and disability insurance, but not health insurance. This could certainly be a state by state thing, and your state may be different. Passing those exams still wouldn't qualify someone for coverage if there is something in their medical history.



Quote:
well. since that insurance company have reviewed his uncle's health by the assigned doctor . that's means they admitted the uncle is under their requirements so the uncle insured there. if the uncle really was sick from then but the company still insured him that means they cheat his uncle.




No. The insurance company isn't capable of doing a complete review if the insured fails to disclose material information. It's not just up to the insurance company to discover what is wrong with someone at time of application; it is also up to the insured to disclose all material information.



eddiellk, is this a health policy in the U.S.? If not, none of us know what we are talking about, so please ignore all of the responses. If it is, we're missing too much information because this just doesn't add up.
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