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Infolawyer
Infolawyer, Attorney
Category: Personal Injury Law
Satisfied Customers: 1076
Experience:  Licensed attorney helping individuals and businesses.
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I have a friend in home hospice. He had 2 separate

Customer Question

Hello,
I have a friend in home hospice. He had 2 separate health insurance policies with the same health insurance company.
One policy was for cancer and one policy was for paralysis.
He was paralyzed by tumors and has been confirmed to bed for many months. He does have cancer too. His wife is looking for help on how to get the separate policies to pay for the hospice care. The health insurance says that they won't pay for paralysis because it was caused by an illness, but in the policy it does not state limitations for causes, just that it does cover things like paralysis, heart attacks, etc. Then there is a separate policy for cancer which is covering hospice. But the family needs both plans to pay because the paralysis has required the wife to stay home and not be able to work, etc. I can I help these people?
Submitted: 1 year ago.
Category: Personal Injury Law
Expert:  Infolawyer replied 1 year ago.
Normally, the insurer decision is challenged as improper attempt not to cover. You would get the policy and check if the issue has been disclaimed or not covered. May also pursue appeal with insurer personally or through counsel. May further seek intervention of insurance department and court order seeking declaratory judgment of coverage.
Customer: replied 1 year ago.
The answer does not make sense. my friend was denied coverage for a second policy that states it covers paralysis.
And yes she can appeal, but on what grounds?
Expert:  Infolawyer replied 1 year ago.
she can only appeal if the policy provides coverage and insurer wrongly is denying it.If the policies do not cover her condition, friend would need to pay the balance or work out a reduced amount and payment plan based on financial hardship
Customer: replied 1 year ago.
Her husband took out 2 separate policies
one was for cancer
and the second one was for paralysis, we looked through her plan and it states "paralysis: spinal cord injuries…loss of 2 or more limbs for continuous 30 days" her husband had all this and a statement from the doctor - the insurance company says they will not pay because paralysis was caused by illness, cancer, but it does not say how a person must be paralysised to receive coverage
Expert:  Infolawyer replied 1 year ago.
If the policy is vague then it would be interpreted in favor of the insured and against the insurer.Typically a lawyer would negotiate with the insurer and its counsel, and if needed sue for a declaratory judgment to get an order finding there is coverage.
Customer: replied 1 year ago.
I don't feel like I am getting any new information that I didn't have already. Are you saying the only way to deal with the insurance company is to get a lawyer?
Expert:  Infolawyer replied 1 year ago.
You may directly negotiate with the insurer, through an adjuster, with insurance department or court. A lawyer is helpful with those options but not mandatory.
Customer: replied 1 year ago.
ok, thanks. I don't feel like my question was answered directly.
How can an insurance company get away with selling their policies and then not cover when a person needs it? It seems unethical and illegal. The insurance co is supposed to pay for hospice care. The cancer policy is supposed to pay $50 per day and the policy for paralysis is supposed to pay $100 per day - it is with the same insurance company but they are 2 separate polices to cover separate health issues…. even though the illness may be connected. How can an insurance company sell 2 separate policies and only cover for one?
Expert:  Infolawyer replied 1 year ago.
That is a good question, and where misleading, the court is more likely to make them cover!