Life Insurance Claim Reconsidered Through Medical Clarification

A consumer contacted our office after her husband’s life insurance claim was denied. The insurer took the position that coverage would not have been issued had it known he had diabetes prior to applying for the policy.

During our review, we noted that the medical information appeared less clear than initially presented. While one test result showed elevated blood sugar levels, there was no clear indication in the medical records that a diagnosis of diabetes had actually been made before the insurance application was completed. We also observed that a letter previously submitted by the physician did not directly address this distinction.

We suggested that the consumer seek further clarification from the physician regarding whether a diagnosis of diabetes had ever been made. The physician subsequently provided a detailed explanation confirming that the single elevated reading did not result in a diagnosis and explaining why the insurer's assumption was not medically supported.

After reviewing the additional information, the insurer reassessed its position, reversed its decision, and approved the life insurance claim.

Consumer Takeaway

Medical test results and medical diagnoses are not always the same thing. If a claim decision relies on medical information that appears unclear or incomplete, obtaining clarification from a treating physician can sometimes make a significant difference.

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Our office helps consumers better understand insurance decisions and can assist in identifying information that may be relevant when requesting a review.