Insurance Disputes

For profit insurance companies are in the business of making money. They do not exist for any other reason. What truly upsets many victims is how insensitive and disinterested the powerful insurance companies seem to be when it comes to the filing of an individual claim. Whether it is disability, health, homeowners, or life insurance, any claim denial is extremely personal to the victim. While each type of insurance policy has its own unique issues concerning coverage and liability, many times denials are based upon application errors and inconsistency in the underwriting process. The Ellsley Law Firm has the necessary experience litigating these types of insurance policies to make sure that the insurance company honors its duties under the contract so that our clients are not taken advantage of.

Disability insurance policies involve issues concerning the physical or mental health of the insured policy holder. People purchase disability insurance as a way to responsibly protect themselves and their families in the event that they become unable to work due to a physical or mental injury or illness. The issue that is most often litigated is the key policy language. Although some policies are “occupation specialty specific”, most policies are simply “occupation specific”. This means that the disability insurance company must begin to pay the benefits once the policyholder presents specific evidence that he or she meets the policy language definition of “disabled”. That language usually defines “disabled” as “unable to perform the substantial and material duties of his or her occupation as a/an (occupation).” To prove that payments of benefits should be made, it is important that expert medical and vocational specialists are retained. The Ellsley Law Firm works with specialists in all fields of expertise to prove to a jury that our client is disabled and should be paid his or her benefits as promised by that insurance company in its policy contract.

Health insurance companies constantly deny treatments and procedures recommended by healthcare professionals. They do so simply to save money. It has almost become a culture within the health insurance industry to initially deny any request for extended or specialized treatment. Denials are based upon many factors and excuses are abound. From “experimental condition” to “not medically necessary” policyholders have heard it all. The key component in the utilization review process (the pre-litigation appeal process) is proper and appropriate documentation from the victim’s current treating healthcare providers. The Ellsley Law Firm works with the treating healthcare providers at an early stage and in an aggressive manner to attempt to resolve health insurance denials before litigation is necessary. We recognize that healthcare providers are often at odds both philosophically and economically with health insurance companies, and we capitalize on that leverage to help our clients.

Homeowner’s insurance claims often arise following natural disasters. Hurricanes, floods, and fires are just a few of the “perils” that an insurance company underwrites. When these and other weather events occur, there is often widespread damage to homes and personal property. People become physically ill from mold caused by damage to their homes and cannot continue to live within the structure. Although insurers will initially react to the events by dispatching numerous claims adjusters to a destroyed neighborhood and set up a base camp very close to the media, many insurers often do not follow through in the subsequent weeks and months. They will offer very little money for the damage. They also delay payment for months. Worst of all, they sometimes create a bogus coverage defense by confusing the policyholder with letter after letter explaining that they are denying the claim because the damage was caused by “water” or “wind” and is therefore not covered under the policy. To get the benefits that a policyholder deserves, The Ellsley Law Firm fights back on a multitude of fronts. We use former industry experts who are experienced in the field of policy drafting and interpretation to demonstrate that the policy language itself is ambiguous and confusing. We establish that the coverage that the insurer says it is providing at this stage after the incident is much more limited and narrower than what the policyholder reasonably expected to have at the time the insurer sold the insured the policy. We also collect and use key primary source evidence to establish the validity of the claim. For example, in a mold damage claim, we hire environmental and biohazard investigation companies to analyze a home, collect samples, and conduct laboratory tests to scientifically prove that the mold exists, was caused by the damage to the home from the subject event, is causing the illnesses claimed, and is covered by the insurance policy.

Life insurance benefits denials are particularly devastating because family members often receive the bad news of a denial at a time when they are already distraught with the loss of their loved one. Fighting with an uncooperative insurance company while going through the grieving process is the last thing that someone should be forced to do. It is particularly frustrating for the family because the decedent was responsible in getting the life insurance and in working hard for many years to consistently pay the insurer the monthly premium. Most life insurers point to omissions or misrepresentations of prior medical history as a basis for refusing to honor the claim. At The Ellsley Law Firm, we fight hard to focus the case on what actions the insurer failed to take during the underwriting process and minimize the emphasis on what information was or was not given by the insured during the application process. For example, to combat the common defense that “the insured did not fully disclose relevant and material prior medical history” we analyze whether the application questions were ambiguous, and we show how the answers given sufficiently provided the requested information but that the insurer failed to perform even a minimal follow up. We also attack the argument by the insurance company that the undisclosed information is truly relevant and material to the underwriting process. To illustrate, in a case in which the insured passed away due to a heart attack, and the insurer denies paying the benefits because the insured forgot to disclose a past surgery for a broken arm on the life insurance application, we show how truly ridiculous it is for an insurer to argue that the surgery to the broken arm was “relevant and material to the underwriting process”.