An interesting case has recently been reported in The Boston Globe. It is a lawsuit about whether or not the State of Massachusetts should be providing insurance coverage for adjunct professors in the public higher education system.
Rather than getting into a discussion about the insurance that a business or governmental agency should be providing its employees let us talk about a specific issue that comes up in health insurance situations. Most of the time when someone buys health insurance they are going to be required to fill out an application which asks questions about the applicants past and present medical conditions.
Almost every health insurance policy is going to have conditions that are not covered by the insurance. The conditions will be pre-existing conditions and also conditions that “manifiest” themselves within 30 days of the inception of the policy.
One Court that has dealt with this issue was in the case, Benefit Life Ins. Co. v. Mizell. In this case the health insurance policy had a provision that contained a “thirty day inception delay”, which stated that the policy did not cover expenses resulting from a covered sickness that first manifests itself within thirty days after the effective date of the policy. The effective date of the policy in this case was April 10, 1993. On a date thirty one days after the effective date of the policy, Mizell was treated for complaints of a knot about the size of a marble in the muscle of his arm. It was at first thought to be a ruptured biceps tendon. It was later diagnosed as cancer.
Benefits Life refused to pay Mizells’ medical expenses and a lawsuit was filed. Mizell won at trial and was compensated $108,652.62. Benefit Life appealed this ruling.
On appeal the trial courts decision was affirmed. The Court reasoned that an illness will ordinarily have its inception for policy purposes “when it first becomes manifest or active or when there is a distinct symptom or condition from which a medical person can, with reasonable accuracy, diagnose the disease”. The Courts said a condition does not necessarily commence when its medical cause began or has its origin but when it becomes manifest or active. The Court defined “manifest” as, readily perceived by the senses and especially by the sight.
In Mezell, the cancer was not manifest within thirty days of the effective date of the policy period. The Court went on to say that the diagnosis must be solely predicated upon distinct symptoms and conditions that Mezell presented during the thirty-day period and not upon testing procedures performed later.
Health Insurance cases can be complicated at times. Usually the case rests not only on the policy language but also on the medical recorders. The medical providers making good records of the dates of treatment and the procedures performed have a lot to do with the success or failure of a claim being denied if a lawsuit is subsequently filed.