Tips on dealing with an insurance company that refuses to pay?

Question

My dad applied for insurance coverage last year, and received a letter dated July 19th that says his insurance was "IN FORCE". Based on that, he scheduled a doctor's appointment for July 24th where it was discovered that he needed a hip replacement. Later, the insurance issued several other pieces of paperwork stating that the "effective date" was July 28th - thus, they say that the condition discovered on July 24th is a "previously existing condition" and is not covered by my father's policy.

He only made the July 24th appointment because the letter received July 19th implied - to him - that the policy was "IN FORCE". He did not receive anything prior to July 24th stating that the policy was not effective until July 28th. But, because the policy was "effective July 28th", the company refuses to pay.

Any suggestions on how to deal with this?

Answer 1

The effective date is not the problem. The insurance company is going to say that when you father applied for coverage he must have known about his hip condition. If it was not disclosed on the application the insurance company can rescind the policy and refund the premiums then he will be liable for all the claims.

If the symptoms were such that a reasonable person would have sought treatment prior to the effective date then it is considered a pre-existing condition.

Your fathers hip could not have gone from problem free to needing surgery in 5 days.

Quite Frankly it will be hard for the insurance company to believe that he was not aware of the hip condition when applying for coverage.

If his medical records indicate he knew about the hip problem that will also make it a pre-existing condition.

I'm afraid there is not much you can do in this type of situation.

Unfortunately Insurance is intended for the unforeseen event, you can get car insurance after your car is wrecked, you can't get disability insurance after you are disabled and you can't get health insurance after you already have a medical condition.

Answer 2

you're gonna have to sue them, litigation is the only language that insurance companies speak.  Good luck

Answer 3

Hoping you keep a copy of the letter, you can prove the date in question.  This will be a HUGE help in discussing a lawsuit against the insurance company.  Once you have the date on the letter and as long as the letter doesn't indicate another date when the policy will be in "full force" then you're set to negotiate, otherwise it's a you said/they state scenerio and you don't usually win those without proof.  Once you have the letter, don't be shy about faxing it to them to make your point.  They will work with you then, for sure.

Sorry I can't be more positive.