When you are disabled due to an injury or an illness, the last thing you should have to deal with is a battle with an insurance company over the interpretation of complex contractual terms to get your benefits.

For example, imagine suffering a cardiac arrest, being hospitalized, and becoming disabled from working only to be told by the insurer that “heart attacks” are covered but “cardiac arrests” are not. Unfortunately, these circumstances are all too common.

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A news story regarding a family man comes to mind. Mr. (name) was a fit man in his mid-30s who suffered a cardiac arrest. He was placed on life support for four days and spent nearly a month in hospital. Following his release from hospital, he was disabled from his occupation as a mechanic because of ongoing issues with his left arm that arose following a surgical implant of a defibrillator.

When he applied for critical illness coverage through his employment’s group coverage carrier, he was denied. The plan purported to treat “heart attacks” differently than “cardiac arrests.”

The insurance company took the position that, while the insured’s heart stopped, it was not caused by a “heart attack”. The insurer defined “heart attack” as the heart stopping due to a blockage. Since the insured’s heart stopped for an inexplicable reason and not due to a blockage, he was deemed not covered. However, the medical community would describe what occurred here as a heart attack.

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What is Contra Proferentem?

Contra proferentem means that where a term is ambiguous, the preferred meaning should be the one that works against the interests of the party who provided the wording. In the insurance context, it’s the insurer who is responsible for drafting standard form insurance contracts. Courts acknowledge that people entering insurance contracts (including disability insurance contracts) have no negotiating power over the terms of these contracts. They accept the terms or they don’t get coverage. Courts also assume that the drafters of these documents are well aware of any limitations or ambiguities and should not be allowed to take unfair advantage of this knowledge. Similarly, if an insurer did not choose its words carefully to avoid misunderstandings, it should not be allowed to benefit from that lack of care.

So, if the normal rules of contract interpretation do not clarify which interpretation was intended by the parties, the courts may apply contra proferentem to break the tie. Some exceptions may apply if the dispute involves an argument over coverage between two insurance companies.

We have resolved many cases favourably for our clients where we have applied this legal concept. You only have a limited time to make an appeal and seek legal action. Contact our Insurance Denial lawyers today at 604.581.7001 to book your free initial consultation.

Read more on 5 additional reasons why your disability claim (could have) been denied.

Don’t Automatically Assume the Insurer’s Interpretation is Correct

An insurer will often deny a claim based on its interpretation of the terms of the policy. Many people simply accept the insurer’s interpretation because, after all, they are the ones administering the policy, and they are assumed to know best. However, it is imperative to review the master policy that sets out the terms of the contract. If there is another, equally compelling interpretation that would cause benefits to be paid, that is the interpretation that should prevail. Further, if there are two equally compelling interpretations, the legal concept of contra proferentem has been used as a tie breaker.

Read more on reasons why long-term disability claims are often denied.

Seek Legal Advice from Experienced Lawyers

When your insurance claim is denied, seek legal advice from a lawyer that has specific expertise in insurance matters. It may make the difference between getting paid or getting nothing.

At McQuarrie, we have over 100 years of combined legal experience dedicated to litigating insurance claims, including denials of short and long-term disability benefits, life insurance and critical illness claims. If your claim has been denied, contact us and our lawyers can offer guidance on your options and how to resolve your situation efficiently.

If you have a question about a disability claim denial, call us at 604-581-7001 for a free, no-obligation consultation.

The post Contra Proferentem in Canada and Your Insurance Claim Denial appeared first on McQuarrie Legal Services.

What to Know About Business Interruption, Health, Disability and Critical Illness Insurance?

There are tax and other advantages to self-employment, but creating a safety net of insurance products for you and your family should also be considered. If you are self-employed, such insurance products can be lifesavers in your time of need. As a small business owner if you became disabled or critically ill for a long time, it would likely cause financially difficulty for you and your business. Disability and Business Interruption insurance for self-employed individuals can provide monthly income while critical illness insurance provides a lump sum benefit after a set period (usually called a waiting period).

In addition to the above, there are extended health insurance plans available to purchase that can help pay for medical and dental costs not covered by your provincial government health insurance (MSP). They can help provide protection against potentially costly, unforeseen health care expenses.

What is Self-Employed Disability Insurance?

It is advisable to contact an insurance broker to see what products suit your needs. When the “unexpected” happens and you’re unable to work, a self-employed disability policy will provide some income replacement, usually expressed as a percentage of your average monthly earnings. If you’re self-employed, you can buy self-employed disability insurance. The taxability on this income depends on how the premiums are paid or structured. If the premiums are paid through a professional corporation, the benefits may be taxable in your hands. If the premiums are paid personally, the benefit may not be taxable. It is important that you seek the advice of a broker and accountant on how best to set up the coverage.

What is Critical Illness Insurance Coverage?

One in four Canadians will suffer a critical illness by age 65, and the costs related to critical illness continue to rise. Critical illness insurance is designed to protect policyholders who become critically ill or injured. If you are self-employed, critical illness benefits can be crucial to your financial survival.

Such policies provide a lump-sum payout. The amount would be set out in the policy you purchased and based on your needs usually in consultation with an insurance broker. If your illness meets the criteria set out under the policy with no applicable exclusions, you should be entitled to the benefit.

What to Know if Your Claim is Denied

The insurance policy terms are contractual and subject to interpretation. That is why if your claim is denied by the insurance company in your time of need, consult a lawyer as soon as possible. Time limits are not the same for every policy and each circumstance is unique. Therefore, it is essential to get legal advice to know what time limits apply in your particular disability circumstance.

Read more: Five reasons why disability claims are often denied.

Self-employed disability claim cases are often denied for lack of medical evidence. Our disability claim lawyers have successfully resolved these denied claims by producing medical evidence required to prove the disability defined under the policy.

Need Help with Self-Employed Disability or Critical Illness Claim Denied?

If you, or a family member, have become disabled and critically ill, and your insurance claims are being denied, you need expert advice from experienced disability and critical illness lawyers for a fair and equitable resolution of your claim.

In addition to meeting the definitions for insurance coverage, there are time limits for all critical illness and disability insurance claims. Any delay in proceeding may be subject to a deadline. You should not hesitate in starting your claim or obtaining legal advice to clarify both definitions and deadlines.

 At McQuarrie, we have over 100 years of combined legal experience dedicated to litigating insurance claims, including denials of short- and long-term disability benefits, life insurance and critical illness claims. If your claim has been denied, contact us and our lawyers can offer guidance on your options and how to resolve your situation efficiently.

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Have you been denied your insurance claim? Contact one of our experienced insurance denial lawyers today. We work on a contingency fee arrangement so there is no up-front cost to you, and you only pay a legal fee if the insurer pays you.

Contact us at 604.581.7001 for a free initial consultation.

The post Self-Employed Individuals: A Few Points About Insurance Coverage appeared first on McQuarrie Legal Services.