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Life, Health And Disability Claims
By: Gregory G. Wimmer, CLU, ChFC, CSSC, LHIC |
Most disputes arise in the area of claims. This results because for whatever reason, some sound and others speculative, the claim is denied at the death, disability or sickness of the insured.
In the life insurance context, disputes often arise when there is an early death, specifically during the contestability period. Carriers have the right to contest claims presented during the first two years of a life insurance policy. This feature allows them to reverse underwrite and investigate the circumstances and condition of the insured at the time of the application. Often, they will discover information not initially reported either through intentional omission, simply not requested or requested and provided but disregarded, as deemed unimportant.
Claims made under health insurance and disability income contrast with life insurance in that the information required and deemed important by the carrier can be different than that for a life insurance policy. In these two coverage s, of paramount importance is the revelation of any pre-existing condition that may bear on future claims.
It is imperative that the agent and the underwriter responsible for evaluating the risk for the carrier be open and honest with each other. This is necessary for the insured to know that should an early claim be made, there are no grounds for rescission of a policy or denial of a claim due to a failure to provide timely and essential information during the underwriting process.
Carriers have not only the right but the duty to investigate claims and to make certain they are only paying claims on policies that are in force and the claim is being made on a loss for which the insurance is providing coverage.
Gregory G. Wimmer, CLU, ChFC, CSSC, LHIC, is a veteran of the Life, Health and Annuity Business. Mr. Wimmer has been retained in both federal and state courts in 26 states. He has the requisite background to render opinions in Life Insurance Underwriting, Agent and Broker Standard of Care, Life Insurance, Health Insurance, Annuities, Disability Income and related areas.
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