I Need Some Help

[Gadjit]

Hello, This is my first post after finding this site, and I am certain this will be a valuable resource for me in the future!

My issue is this....I am being sued and I dont have E&O!

That aside, my problem is this, I showed a client a plan of insurance with a 12 month wait on maternity, she got pregnant before it ran out and is now suing me for medical costs. She states that I told her she had maternity, and never informed her of a waiting period. I did inform her verbally and sent 2 separate emails with Company brochures attached that said no maternity. Additionally, my state allows for a 10 day free look on health insurance, and her policy states no mat coverage for 12 months.

Basically she did not read anything I sent her or anything she got in the mail until after she was preggnant and now needs someone to pay for it other than her.

I am hiring an attorney, but has anyone ever heard of any cases regarding this issue? (client responsibility to read material for themselves) or anything else that may help me out?

I am confident that I will win, I just want to make sure I have all the info I need.

Thank you so much for any help you have.

Gadjit

 

[Slim]

Re: I Need Help

I probably I should let an expert here handle this but since no one has jumped in and Gadjit's topic caught my interest.. here ya go :



Quote:

"Hello, This is my first post after finding this site, and I am certain this will be a valuable resource for me in the future!

My issue is this....I am being sued and I dont have E&O!

That aside, my problem is this, I showed a client a plan of insurance with a 12 month wait on maternity, she got pregnant before it ran out and is now suing me for medical costs. She states that I told her she had maternity, and never informed her of a waiting period. I did inform her verbally and sent 2 separate emails with Company brochures attached that said no maternity. Additionally, my state allows for a 10 day free look on health insurance, and her policy states no mat coverage for 12 months.

Basically she did not read anything I sent her or anything she got in the mail until after she was preggnant and now needs someone to pay for it other than her.

I am hiring an attorney, but has anyone ever heard of any cases regarding this issue? (client responsibility to read material for themselves) or anything else that may help me out?

I am confident that I will win, I just want to make sure I have all the info I need.

Thank you so much for any help you have.

Gadjit"

END QUOTE


In my humble opinion , if you are hiring a lawyer your lawyer should already have told you everything you need to know to calm your fears...
And you should go by what your lawyer says since you are hiring him... until you fire him if you think necessary.

Second I do not see how any Health Insurance Company could have let you go out there and represent the product and Company with no E&O Insurance.

Third, if you have been in the biz any length of time or listened closely and taken to heart anything the Licensing School and / or the Licensing test should have or did teach you then you would or should know on your own to be protected from E&O claims.

Fourth , that being said and giving you the benefit of the doubt that you already knew what I said above,
a) You now need to trust your own records.
b) Trust your own documentation.
c) What you said above is that you documented and you gave her lots of info written and verbal info which she should have taken to heart and she should be held responsible for overlooking.

Fifth , if the Application has her signature she may have her initials declining any available riders if available . Or acknowledging said 12 month waiting period. If you did not get her initials and if her initials are requested in any of your forms or applications then you could have a problem in that area of her claim. If you have any supplemental addendum forms required for waiting period then you better have included it in your presentation and gotten signed if applicable.

Sixth , You need to review all your paper work and listen to the lawyer if you are getting one. Disregard all my info herein because I am not a lawyer and am not practicing law on this fine forum in any state or entity.

But you need to review your documentation and hope it never makes it to court because hopefully you can slam dunk her complaint out of court with a stack of papers and proof showing that you gave your position some forethought and your client some level of care she and you and your community can brag on.

Seventh, After you do that then you may even be able to conserve her business and get som referrals and write life on her with a child rider in case the unfortunate event her child does not make it long after birth.

Also you need make sure you do not stress her over this as she may stress you. And you need to briefly tell her how to get out of her fear of being without maternity insurance : Maybe her hospital has a prepayment and post payment structure (financing) or maybe she can go find a good hospital in the area which does.

Eighth, Do everything through your lawyer and company lawyer and company support and upline . That is why they get the big bucks.

I guarantee the company covered and the underwriters covered themselves. The company has deeper pockets than you. Surely if she really has anything to go on, you will not have to go in the lions den alone because at the very least her and her lawyers are going after more than you for the money.
Hope she does not have money to go against you in court.

Ninth, Hope you don't live in CA.

If you live in CA you might want to start selling your house and car and clothes on your back and take it all to court and pay up.

Good luck.

PS She probably signed a disclaimer on application stating no agent has authority to verbally or in writing change any agreement on Company forms and on Company sales documents. And it's stated on Policy also probably when delivered to her after effective date.

And she also should have had a review after she received the Policy delivery. So her claim of any verbal alleged promise does not override the COMPANY DOCUMENTS THAT PROBABLY CLEARLY STATE UP FRONT "THERE IS A WAITING PERIOD ON HER MATERNITY". Sorry . you mentioned it above. Sleep well .

When she signs an application I believe she is signing that she has read the text at least above her signature and understands and knows what she is signing.

Countersue for defamation of character then follow plan of conserving current policy!!!!

PSSS Oh yeah don't take any of this as legal advise . I am not an attorney nor am I practicing law in your state or any other state or country. I am not giving legal council either. Nothing herein written or implied or inferred should be construed or taken as legal advise. Be advised only by a professional . These are just opinions from common industry knowledge. These statements are from my own opinionated opinions. Above statements are for academic hypothetical debate only!!!!

 

[xrac]

Re: I Need Help

Get some E&O for the future. $400 spent for E&O would sure go along way now. Let this be a warning to anyone planning on doing without E&O.

 

[Gadjit]

Re: I Need Help

Thank you Slim for your advice. I know I should have had E&O, but let it go several years ago due to increase in $$ (I was actually paying nearly 2K per year for it! Now that seems like pennies comparatively speaking.

I was actually wondering if anyone had any information on what the actual client responsibility is when searching for a policy and is there any case out there that actually defines due diligence in pre-sales events.

33-29-11 Georgia code is helpful, (free-look law) but I would like to find actual cases where things like this have happened before and what the outcome was.

Thank you all for your opinions and help...........


Now go out there and get that E&O if you dont have it!!!!!!! Take it from me, you want it if you ever need it! And your Umbrella policy does nothing for you in this case.

Thanks again, please keep the info coming,

Gadjit

 

[myinsurebiz]

Re: I Need Help

Get some E&O for the future. $400 spent for E&O would sure go along way now. Let this be a warning to anyone planning on doing without E&O.

It's simply a business expense, and a cheap one at that considering the lost revenue incurred by a suit and defending a suit . . .

Xrac - well said.

Tom

 

[NewHealthStrategies]

Re: I Need Help

Settle for $3,000 and call it a day.... cheaper in the long run. Seeing how most non-complicated vaginal deliveries can be had for under $5,000.... and assuming a normal deductible/co-pay.... she might bite and you can THEN go and get some E&O coverage to protect you.

Hard lesson to learn... but swallow the pill and move on... you'll sleep better.

 

[Winter_123]

Re: I Need Help

Settle for $3,000 and call it a day.... cheaper in the long run. Seeing how most non-complicated vaginal deliveries can be had for under $5,000.... and assuming a normal deductible/co-pay.... she might bite and you can THEN go and get some E&O coverage to protect you.

Hard lesson to learn... but swallow the pill and move on... you'll sleep better.

I wouldnt settle if he has the documentation that he said he has as far as communicating that maternity is not covered.

Keep in mind that the E&O insurance is not guaranteed issue either. If you have had a complaint and especially if you have had to pay to settle then your E&O is not going to be $400 a year.

 

[Charpress]

This whole area is so friggin' unfair.

I had a complaint that never went forward and, in fact, was dropped. My carrier still charges be more based on the complaint, not on the fact the complaint never cost them a dime.

There are always people who are going to try and screw you and this woman sounds like one. Either she is dishonest or she is stupid. She may be both, which in my experience is a dangerous combination.

The main thing E&O gets you is "free" legal representation (after the deductible). Unfortunately, insurance companies tend to settle these things for economic reasons. My own insurance company gave me the choice of letting them settle or not. When I would not let them settle, the case was dropped.

 

[OHInsAGNT]

Re: I Need Help

Thank you Slim for your advice. I know I should have had E&O, but let it go several years ago due to increase in $$ (I was actually paying nearly 2K per year for it! Now that seems like pennies comparatively speaking.

I was actually wondering if anyone had any information on what the actual client responsibility is when searching for a policy and is there any case out there that actually defines due diligence in pre-sales events.

33-29-11 Georgia code is helpful, (free-look law) but I would like to find actual cases where things like this have happened before and what the outcome was.

Thank you all for your opinions and help...........


Now go out there and get that E&O if you dont have it!!!!!!! Take it from me, you want it if you ever need it! And your Umbrella policy does nothing for you in this case.

Thanks again, please keep the info coming,

Gadjit

I'm sure you realize this now, but it doesn't seem like a good plan to try and convince people they need insurance while simultaneously thinking you do not. Best of luck to you on this one. I hope you do have the documentation.

 

[HomeService]

only certain carriers like maybe united american or some company such as that, would let you get by without E&O... but yeah, you should have it....