DENYING CLAIMS
You are driving around in your vehicle running your work errands, when suddenly a pickup truck crosses the centerline from the other direction and smashes into your vehicle. The accident is devastating. You are seriously injured and left in a coma. When you come to, ten days later you have several broken bones, collapsed lungs, and you are headed to spend the next few painful months under constant health care.
And then comes the real kick in the teeth. Your insurance company denies your claim. They claim the driver who caused the crash acted in a moment of deliberate road rage, and so the accident was not an “accident.” Your hospital bills pile up, you are too injured to go back to work, and your insurance company has deserted you.
Here is another scenario. Because of prolonged ill health your mother is unable to care for herself. She needs home care to get by. Thankfully she purchased a long-term care insurance policy over 12 years ago and has been faithfully paying the premiums ever since. She was determined that her children should not suffer the burden of paying for her care much later in life.
She decides to claim for payment from her insurance company, but the payment from the insurance company never comes. You call the insurance company over and over and send them document after document. But they deny the claim, citing reasons ranging from “the claim is too late,” to “you did not fill out the paperwork,” to “you filled out the wrong paperwork.” The denials change each time, often citing provisions in the policy that do not exist, and often contradicting previous denials.
Mean while, the cost of care has quickly depleted your mother’s savings, and now the bills fall on you – her children. The very prospect she sought to avoid is now a reality. In plain language, the bottom line is that insurance companies make money when they do not pay claims. They will do anything to avoid paying, because they know that if they wait long enough, the claimants will eventually die.
Confusing consumers. Your house sustains heavy damage from wind and rain during a storm. The storm surge floods your home 2 hours later. Despite the destruction, you are consoled by the fact that you purchased insurance against damage caused by bad weather, as part of your home owners policy.
Your home sustains thousands of kwachas in damages, but you are confident that it is covered by your insurance company. You are wrong. The insurance company points to the “anticoncurrent” clause in your policy. “I have insurance against heavy storms, because they are part of bad weather,” you counter. But it does not matter. Heavy storms were not covered. How could you have known that heavy storm damage would not be covered in the bad weather policy?
“You should have read your policy properly” says the insurance company, and points to some incomprehensible legal jargon headlined as an “anti-concurrent” clause in your policy. The kicker? It is then that you realize that you did not fully read the policy before you bought it. Insurers will generally attempt to convince the customer when selling the policies that everything is covered and convince the court when a claim is made that some eventualities are not covered.
Abandoning the sick; you receive the jaw dropping news that you have cancer. It is operable, and with prompt medical intervention, you have a chance to survive. You make it through the surgery and begin chemotherapy treatments. Then the insurance company suddenly cancels your insurance retrospectively. The reason? They allege that you lied about your weight on your insurance application. Now you are left with thousands of kwachas in medical bills to pay, unable to afford the rest of your chemotherapy schedule, and facing an uncertain diagnosis.
Cancelling because of a call; a heavy storm causes a water leak in your house roof. The damage is extensive, so you call your insurance company. But along the way, you are reluctant to make a claim on your home owners insurance policy because you are afraid that the insurance company may raise your insurance premiums, as you could be upgraded to high risk. So you pay for the repairs out of your own pocket. It is a big cost on your part, but in the long run, you feel, it will be worth it. But when time comes to renew your insurance policy, the insurance company has a horrible surprise for you. They are not raising your insurance premiums, they are dropping you altogether. Even though you never made a claim, the insurance company documented your phone call and treated it as a claim and considers you to be a high-risk customer.
Few people know that even calling your insurance company can land you in problems. Many people are reluctant to make small claims on their home insurance for fear their insurance company will increase their premiums or refuse to renew their policy. Some might think the small repairs everyone has to make are exactly what insurance is supposed to be for, but in this day and age insurance companies operate under a “you use it, you lose it” policy. Always be careful and cautious when dealing with your insurance company.
Just by making that phone call you increase the chances of your insurance company dropping you at the first opportunity. Insurance companies may treat the call just as they would treat a claim - as a black mark on your record. Even if you call your agent and not the insurance company directly, you are likely to face the same fate.
What can you do about it? Read your insurance policy carefully before buying it: You should know exactly what is covered and what is not covered, and how to appeal against a denial by your insurance company.
Be very careful when filling out insurance forms and never take any thing for granted. Even if you make a genuine mistake your insurance company may use it as a reason to retrospectively deny your coverage and insurance claim. They would allege that you made false declarations, and make you forfeit your claim or insurance cover.
Do not cash a premium refund check; If your insurance company nullifies your insurance policy they may send you a refund for the premiums you paid. Cashing it may be interpreted as accepting their decision. Put everything in writing; Calling your insurance company is likely to be a frustrating experience, and you will not be able to prove anything that a company representative tells you over the phone. Visit your insurance company personally and avoid making phone calls.
Keep records of all bills and correspondence. You may contact your National Insurance Regulator, they may be able to give you some guidance. But they will not represent you in a private matter, so if all else fails you may need to consult a Lawyer.
And most importantly, never give up. Giving up should never be in your vocabulary. This is because insurance companies count on you giving up. Fight for your insurance cover entitlements.
Keep records of all bills and correspondence. You may contact your National Insurance Regulator, they may be able to give you some guidance. But they will not represent you in a private matter, so if all else fails you may need to consult a Lawyer.