Many deserving claimants, who absolutely should have been paid, are swindled out of hundreds of thousands or even millions of dollars in insurance benefits based on the intoxication exclusion. The sad thing is, those benefits were meant as financial protection that their loved ones paid for and wanted them to have.
These swindled claimants largely fall into three categories: 1.) Those who trust that the insurance company’s denial is correct; 2.) Those who think a denial is unfair, but don’t believe that they can beat big insurance companies, so they just give up; and 3.) Those who try to fight an unfair intoxication exclusion clause defense without the help of an experienced ERISA attorney. The insurance companies, of course, love claimants who fall into these three categories.
Many deserving claimants just trust that the insurance company’s denial is correct. Insurance companies know this, and deny legitimate claims knowing that they’ll get away with many denials because honest claimants wrongly assume the insurance company is honest too. The insurance companies’ claims personnel are well trained to display empathy and compassion to the claimant during all communications to build trust.
This leads many to accept unfair denials and go away without even attempting to seek an attorney’s advice, take an administrative appeal or file a lawsuit.
Many people understandably feel that if they choose to fight a claim denial, the insurance companies will win. After all, big insurance companies do have seemingly unlimited resources, and hire some of the biggest law firms in the country to represent them in court. And the claim and administrative appeal process can be time consuming, and require legal expertise to handle properly.
This is especially true if the case ends up in federal court. So many claimants, even if they believe a claim denial is bogus, still give up and go away without attempting to seek an attorney’s advice, take an administrative appeal or file a lawsuit.
Many people understandably believe that if they make a well-reasoned argument to the insurance company on administrative appeal, the insurance company will “see the light,” be fair, reverse the denial and pay benefits.
Where most claimants lose, without knowing it, is during the administrative appeal process. The way most claimants lose here is by failing to assure that ALL evidence conceivably helpful to the claimant is gathered and properly made part of the administrative record during that process before filing suit.
The fatal result is that the judge cannot consider any evidence gathered later when the dispute inevitably lands in federal court after the insurance company denies the claim on administrative appeal.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded the Law Offices of J. Price McNamara, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts