Insurance Disability Insurance

Lost Disability Policy Rebuilt After 10 Years - Court Rules CIGNA Must Pay

Some claims can arise many years after the event that caused disability.
This is highlighted by a case that arose in New York in 2008.
The man seeking benefits had participated in a special accident and sickness policy issued by CIGNA while he was employed as a volunteer with the Shirley Community Ambulance Company.
The policy not only covered accidents that might occur on the job.
It also covered illness that might appear at a later time due to exposure to body fluids during the performance of daily duties.
The man in this case resuscitated a victim of an overdose in one of the drug houses in the city.
As he was assisting the man he was stabbed in the finger by a used needle.
He was treated for tetanus and put on a course of AIDS protocol drugs for a whole month.
After this he was told that he would need to follow-up lab work at three, six and 12 months.
Even if the tested clean at 12 months for AIDS or hepatitis, he was to continue testing every year thereafter.
The year was 1994.
The man did not become ill enough to claim disability until 2004, 10 years later.
In the passage of time, the man who lost his copy of the insurance policy, but he still had a copy of the letter notifying CIGNA of his injury.
When CIGNA checked its records, it did not have a copy of the policy because it was the company's policy to destroy any records that were older than seven years.
The ambulance company also had cleared all records that were older than seven years.
The man wanted to bring a claim against CIGNA, but the company would not recognize the claim.
His disability attorney asked the court to recognize the uniqueness of the situation and accept the evidence that his client was able to produce to prove that he had a claim.
Both CIGNA and the disability attorney agreed that a case known asGold Fields Am.
Aetna Cas.
And Sur.
provided the guidelines the court should use to measure the quality of evidence.
"Specifically, an insured may prove the contents of a missing insurance policy using secondary evidence, and must do so by a preponderance of the evidence.
" The preponderance of evidence that would be acceptable was 1) oral testimony, because the original document had not been destroyed in bad faith; and 2) photographs of the original document or attachments.
There were five pieces of evidence that collaborated the man's claim that he had a right to disability benefits.
  1. The Commissioner of the Ambulance District in the town of Brookhaven testified that the CIGNA policy had been reviewed specifically for its coverage of sicknesses that could take some time to manifest, such as AIDS or hepatitis.
    The Commissioner understood that these were pathogens that volunteers were at special risk for exposure because of the district which the ambulance served.
  2. A copy of the policy purchased to replace the policy dated been held with CIGNA which also covered delayed sickness that arose out of an incident causing exposure to an infectious disease.
  3. The Commissioner of the ambulance district of the town of Brookhaven testified that the new insurance policy was equivalent to the CIGNA policy.
  4. Proof that CIGNA had been notified of the needle stick within 72 hours.
  5. Testimony from one of the other EMTs who had been working at the same time that the infectious disease coverage had been a serious concern at that time.
    The EMT also noted the ambulance company used records of the calls to confirm an event if the claim arose.
CIGNA's response to this evidence was to produce a policy that it claimed was a representation of the policies they were issuing at the time for accident coverage.
Because the policy that was produced did not reflect a policy that also covered sickness, the Court found that it wasn't an equivalent policy.
Finding that the witness of the Commissioner and the policy that replaced the CIGNA policy were sufficient to represent what type of coverage the man would have received under the CIGNA policy.
A review of his medical record demonstrated that the man had been disabled since December 2004 and would've been entitled to benefits under the replacement policy.
Thus the court found that he was entitled to benefits under the policy that existed when he made his claim.
The determination of what his benefits would finally be are not yet in the public record.
In fact this might be settled directly with the insurance company and never enter into public record.
Proving a claim this many years after injury occurred is a challenge, especially when a policy has been lost.
This case highlights the importance of safeguarding your copy of the disability insurance plan, especially when that plan provides for future disability benefits that are based on an injury that may take years to manifest.
Io matter how many years have passed don't destroy an insurance document that may prove your claim.
You may not be able to secure credible witnesses, and disability insurance company's documentation may be stronger than CIGNA's was.
Leave nothing to chance with a disability insurance company.

You might also like on "Insurance"

Leave a reply