The lawyers at Aaron Waxman & Associates are experienced with Disability, Personal Injury and Employment claims.
The Alberta case of Duke v. Clarica Insurance involves the denial of a critical illness insurance claim.
Mr. Duke was diagnosed with Parkinson’s Disease. He applied for critical illness through Clarica in 2001 and purchased a policy for critical illness coverage in the amount of $500,000. He submitted a critical illness claim on May 15, 2003, accompanied by an Attending Physician’s Statement. The Statement was completed by a neurologist.
He was advised that his claim was denied in September of 2003.
Parkinson’s Disease was a covered critical illness under the policy. Clarica stated that according to reports they had received, Mr. Duke’s medical history revealed symptoms of Parkinson’s Disease as early as 1997, before the policy came into force, therefore they were denying the claim.
The Court was faced with the task of deciding two crucial issues, which can be applied to critical illness claims:
1. Is the Exclusion Clause Ambiguous?
2. Does the Plaintiff Qualify for Benefits?
The Court found that neither Mr. Duke or any of his treating physicians or assessors had associated his earlier symptoms with Parkinson’s disease prior to issuing the policy. The Court also found that the Plaintiff had no obligation to disclose these physical concerns at the time. They were generalized symptoms. The wording of the exclusion clause was found to be ambiguous and the Court found that it did not apply and that Clarica improperly denied the CI benefit.
With respect to the second issue, the Court deemed that Mr. Duke required substantial assistance in order to perform his activities of daily living and satisfied the criteria needed to require a critical illness benefit.
Mr. Duke was awarded damages in the amount $500,000, the amount of the critical illness insurance claim benefit.
Clarica appealed the decision and lost.
The judgement states: “Finally, it is agreed that the respondent was completely honest and forthright in his disclosure and did not in any way misrepresent or conceal his condition or his general state of health from the appellant, nor did he attempt to mislead the appellant.”
The full case can be found here: http://www.canlii.org/en/ab/abca/doc/2008/2008abca301/2008abca301.html
Aaron Waxman and Associates is a Toronto Personal Injury Law Firm. We handle critical illness insurance claims. If your critical illness insurance claim has been denied, contact us for a free, no obligation consultation.
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