Arguments To Use Against An Insurer's Denial Of A Health Claim

An insurer may allege misrepresentation of medical facts in the insurance application. This usually occurs when an insurer alleges that the insured failed to disclose a preexisting health condition in the application.

The common reason that brings this reason for claim denial to the fore is when an insurer compares your answers on the application to the information in your medical records. This frequently occurs if a claim is made relatively soon after the policy issue date.

If a condition existed before the issue date of the policy, the question becomes the definition of a misrepresentation contained in the policy. Often the definition refers to a condition the applicant knew about, or had treated within 6 - 12 months prior to the issue date, or is a condition that a prudent person would have had treated in that period of time.

Generally, insurance consumers are not expected to be medical experts. They are simply expected to report their medical condition as they honestly and reasonably believe it to be. For example, a cough before the application date which was not sufficiently bad to drive a person to seek treatment is not necessarily a misrepresentation when the insured is diagnosed with lung cancer soon after the issuance of the policy. 

Likewise, if a doctor notes a disease, condition or sympton in the patient's record, but the patient does not know about it, there is no misrepresentation.

Counteract an argument of misrepresentation by showing that you did not know of the condition that surfaced after issuance of the policy. Your doctor, friends and co-workers with whom you have daily contact may be good sources to help prove what you did, or did not, know.

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