Article content continued
A pre-existing illness is another. Policies (albeit no two are the same) will not usually cover you for illnesses or symptoms associated with the critical illness if you saw a doctor for them in the year before you started the policy. A proverbial gray area in which a lawyer can indeed help. For example, in one case a man had reduced function in his leg and arm. Neither he, nor his doctor, ever associated the symptom with Parkinson’s disease prior to obtaining coverage. Shortly after purchasing the policy, he was diagnosed with Parkinson’s. The insurer denied the claim based on the prior symptoms’ exclusion. But with the assistance of counsel, the court ruled in his favour by construing the technical exclusion clause narrowly against the insurer. The point being, pre-existing illness clauses are susceptible to attack.
Third, claims that do not fall within the list of covered illnesses or the precise definition of a particular illness are also denied. If it’s not on the list, there is no coverage, and not much can be done about it. Whether the illness meets the definition is another gray area, however.
For example, one of our clients fought with an insurance company for months over whether he, in fact, had suffered a heart attack. It was seemingly an obvious approval. But, the technical policy definition of “myocardial infarction” (aka heart attack) was enough to make most readers’ eyes gloss over. We obtained and submitted the proper cardiologist reports along with an opinion from an independent medical professional to bolster our position. The claim was paid.