Q: Is a supplemental medical Insurance company allowed to overrule “multiple doctors” severity of diagnosis determination?
“On December 28th of 2023, my wife became critically ill with Flu “A” and severe double pneumonia. She was taken to a hospital in Oklahoma City and placed on a ventilator. Sadly my wife suffered a hypoxic brain injury due to the lack of oxygen her brain was getting. Now she is in a nursing facility and can’t do “anything” for herself. She requires 100% care 24 hours a day. Long before this all happened, I took a critical illness policy out with Washington National for my family. When I tried to file a claim, Washington national said my wife’s wasn’t critical by their standards and denied her claim. In other words, even though the effects of her illness was the same as a stroke, it’s still not listed as a critical illness by their standards because it’s not labeled at stroke. Same effects, but not a stroke.
Can they legally deny my wife even though all the doctors say she was and is critical?
A: A Texas or Oklahoma attorney could advise best, but your question remains open for a week. I'm sorry for your wife's ordeal. Carriers do deny claims on the basis of differing medical opinions. Only a local attorney could advise on the validity of the carrier's denial under state-specific consumer and insurance laws. However, in many instances nationwide, options sometimes include filing suit or arbitration. If you could arrange a free initial consult with a law firm that handles health care claims/denials, they could review the policy, the basis of the denial, the supporting medical opinions/treatises offered by the carrier to support the denial, the supporting exam/document peer review offered by the carrier to support the denial, wife's medical chart, state laws, and other materials. Good luck
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