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Insurance Denials: The Story of John

In life, unexpected challenges can arise, leaving us vulnerable and in need of support. Imagine being unable to work due to a debilitating condition, only to have your disability benefit claim denied by your insurer. This was the harsh reality for one individual, a long-haul truck driver, whose story highlights the importance of knowing your rights and seeking assistance when faced with unfair denials.

Meet John

Meet John, a hardworking truck driver who found himself in dire straits when back issues left him unable to continue his job. Despite diligently paying into his disability insurance policy, John’s claim was rejected by his insurer, citing a pre-existing condition clause. Faced with mounting medical bills and uncertainty about his future, John refused to accept defeat.

That’s when he turned to A de Bruyn Attorneys, a firm known for its dedication to fighting for justice on behalf of its clients. With our expertise in complex legal matters, John learned that he had options beyond simply accepting the insurer’s decision. By appealing to the National Financial Ombud, he could challenge the denial and seek the benefits he rightfully deserved.

In a recent decision by the National Financial Ombud in a dispute over a disability benefit claim where the insurer denied coverage based on a pre-existing condition clause. The complainant, employed as a truck driver in July 2016 and insured under a group risk policy starting November 2016, submitted a claim for disability benefits in February 2018 due to back-related issues. The insurer rejected the claim, citing symptoms experienced prior to coverage.

The insurer relied on a medical report from November 2017, indicating the complainant experienced symptoms dating back to 2017, with a history of chronic lower back pain since a train accident in 2003. However, the policy stipulated that benefits are not payable if the insured becomes totally disabled within 12 months of cover inception due to pre-existing conditions.

Upon review, it was noted that the symptoms mentioned by the doctor only started in 2017, with documented consultations from March 2017. Additionally, a medical report from June 2016, related to obtaining a driver’s license, showed no indication of muscular incoordination. The insurer failed to provide specific evidence of symptoms within the six months preceding coverage inception.

In response to queries, the insurer admitted the claim, acknowledging the lack of sufficient evidence to prove the pre-existing condition within the stipulated timeframe. Consequently, the disability benefit was paid to the complainant.

The case underscores the insurer’s obligation to furnish medical evidence demonstrating, on a balance of probabilities, the existence of pre-existing conditions and their causal link to the disability claim event.

At A de Bruyn Attorneys, we understand the frustration and stress that come with battling insurance companies. That’s why we’re committed to providing compassionate and effective legal representation to individuals like John who find themselves in similar predicaments. Our team works tirelessly to fight for our clients’ rights, ensuring that they receive the compensation they’re entitled to.

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