In the practice of medicine today, the complexity of insurance is infinite, however only becomes a problem when an “event” occurs.
The following story is becoming more typical and frequent than one realizes or would wish.
The patient in question had a severe automobile accident, not his fault, over five years ago. He has lost his business and his home. Throughout this period, he has undergone countless courses of medical therapy, an unending series of tests and many medical and other assessments. As a final insult, he has been evicted from his home due to his inability to service the mortgage. At this time he is living in semi-abject poverty.
Here is his wife’s recounting of the proceedings; she writes as follows:
We trust this is a good moment to bring you up to date. John has been going through countless assessments and most recently, the ones for his catastrophic designation, which will be finally arbitrated at the end of April. The scheduled hearings with all the experts will last over two weeks. The assessments John went through lasted from forty minutes to two days. The medical evaluations that were initiated by the insurance companies and executed by their “selected doctors” did not lack briefness, trickery and manipulation. Their reviews are insincere and dishonest with ample insulting efforts and frustrating moments to disturb and offend the victim. It must be their principle to close all their prejudiced reports with the same findings – to decline anything and everything.
Our side applied for the arbitration, which will take place in front of FISCO, the Ontario government’s controlling body for all insurance issues. FISCO has no power to decide on financial losses and damages of the plaintiffs, but is the organ and consequently imperative for defining the victim’s rights and the insurers obligations (up to two million) for retroactive and future payments regarding John’s care taking, rehabilitation, medication and treatments. The Superior Court of Justice in Ontario will eventually hear the damage claim.
After all, John did not cause the accident.
He was t-boned on a Monday afternoon in October 2007 and his mistake was that he showed up in the wrong place at the wrong time. The result of this error is permanent brain injury, back and balance problems, chronic headaches, etc., the loss of all income with only expenses left, including and not limited to all his equity, retirement savings, valuable life insurance policies etc. and a smashed and beyond repair automobile.
John has been disabled and absent from his business and social life ever since. The seventeen year young driver was charged and pleaded guilty. No support or reimbursement has been presented yet.
Is this a scandal? Yes! Is John the only victim of the insurance system? No!
The last year was most stressful.
We have been constantly working on our financial survival and the reinstatement of John’s treatments that had been cut off by the insurer in 2009. One may question why you have insurance at all when they refuse support and follow through when needed. John’s motivation to have the family well provided for has always been evident. His guiding principle to have any thinkable incident insured and financially secured is fact but has not materialized or manifested in any compensation by today.
What has become apparent is the scandalous reality and truth that he was, is and will be at the mercy of the insurance companies, their counsel and doctors, who are deciding on everything including the timing of when to get treatments and of course the payments. It is just a nightmare. Not to mention that down the road the judges and jury will have a say if no prior settlement is achieved.
Actually, October first 2012 was our ‘fifth accident anniversary’!
John went as far as to obtain through Chubb Insurance an umbrella policy of ten million dollars twenty years ago. This was supposed to provide the safety net in the unfortunate situation of an automobile accident where the other driver has no or insufficient insurance coverage. In our case the other driver was covered for two million under her father’s Toronto Dominion Insurance Policy as the principal car owner.
The pending hearings in John’s family tort claim vs. the driver, her father and their TD Car Insurance as well vs. John’s Chubb personal insurance for amounts exceeding the TD coverage will take place in the ‘Ontario Superior Court of Justice’. Three weeks will be needed for the court hearing in case no pre trial settlement is reached.
John’s different life and disability Insurers in Germany (Allianz Insurance and the Unfall und Renten Versicherung) and Switzerland (Winterthur Insurance and AHV) handled and settled our legitimate claims professionally and timely after they had completed their due diligence and comprehensive and ongoing medical assessments. Contrary to that attitude is the behavior of the two major Insurance Companies at whose mercy we now exist.
Their concept of processing a claim is definitely not based on fact-finding or to provide relief and financial help for the victims and their families. Their well-set principle is based on delaying, declining and intimidating.
This is a “business world” in itself, a kind of an ‘insurance mafia’ where the insurance providers are investing substantial funds for delaying and fighting any claims by well thought out legal maneuvers, by screening the victims to their bones and involving investigation agencies to have the sufferers monitored and followed.
The insurers appointed doctors conducting the so-called “independent” and “non-bias assessments” and the insurers lobby and financial power in the political arena and lawmaking body don’t necessarily improve the victim’s position.
The more you get involved the clearer the concept becomes. It did not come as a total surprise that the outcome of the insurers independent assessments are in reality “prejudiced reports” to hide and justify the insurers disapproving rightful demands. They just decline and the victims are left all over again with the same task on hand… “prove it”. Or to paraphrase, prove what?
Everybody who knows John will confirm that he would be the last one who didn’t want to be on the hospitality world stage anymore.
For the longest time after the accident John was in a denial frame of mind and would not even admit or accept that his days are over and that he had become disabled indefinitely. For him not to be able to be with people and create, lead and execute ideas and concepts any longer is catastrophic.
In a split of a second, he was taken away from his successful, fulfilling and rewarding business, family and social life and confined to being a non-entity.
The insurers self-serving delay tactics by ignoring the numerous non-biased doctors and specialist assessments, by declining treatments and payments and even questioning John’s integrity is totally insulting, wrong and harmful. These insurance companies try to wait the victims out, financially and morally until they give up and throw in the towel, pass away or depart this life voluntarily before any settlement is achieved or just give up and face the financial reality of being ruined permanently. Ever listen to an insurance ad? Total deception!
We try very hard to stay positive, ever getting closer to the boiling point. We truly hope that the latest events are an indication that the parties are moving to ultimately determine the severity of John’s injuries and his ability to continue what he always enjoyed doing.
His whole life shows his dedication to his profession, his total commitment to deliver the best and his always-positive approach to people and life.
All this is evident in his letter “to whom it may concern”, his essay “my life” and “other supporting documentation”, not to mention the medical file with “the assessments, expert reports and treatment history” and the supporter list with the “seventy-seven support letters” our counsel and I received describing John.
If you have interest in any of the credentials, we would be excited and very pleased to provide them to you.
This automobile accident has such a devastating effect on us.
Not enough, that John couldn’t carry on his profession and business that he loved so much, now we no longer have any hope. It has been taken away.
After we had used up our savings, closed both retirement saving accounts, surrendered John’s very valuable and paid up Life Insurance used up all our investments and savings, we were left with no choice than to take our daughters out of their private school, which they had enjoyed for eight years. Last but not least, John’s Royal Bank’s disability payments came to an end in January 2011 when he turned 66. Since that day, only some small pension payments are received monthly.
It has been really tough and believe us, we are looking more than forward to the day when we may be able to show our appreciation to those who have helped.
And now in its sixth’s year we are close to losing our last family asset, which was already highly leveraged for the reasons indicated. John’s Family Trust owns our beautiful home. Most channels have been exhausted. We must have tried every avenue to get our first mortgage increased to a level where we would be able to consolidate the first and the second mortgage into one, and still have an additional amount reserved (escrowed) to secure the interest and tax payments for a period of up to 18 months so that no default could be possible. The property provides sufficient equity but our almost non-existing income stream made any refinancing an impossible task.
Please forgive us for the lengthy and sometimes-repetitive report. We like to tell you how much we appreciate the opportunity to express our thoughts and feelings and were able to describe what our family has experienced going through the last five years and what may be the next steps in our saga.
We are still blessed with our family and we need to carry on until such time as we have found common ground with the Insurers and their troops.
Thank you for listening, thank you for your compassion and thank you for your friendship and trust and your readiness to bear with us.