Thanksgiving Claim

[adjusterjack]

Interesting question from another site. Ponder it while you recover from Turkey Torpor.

The homeowner's guest was eating turkey, started choking and passed out. Family members rendered aid, cleared the item and revived the guest after about a minute. Does the homeowners policy cover any necessary medical testing or treatment arising from the incident?

With all my years in the insurance industry, that scenario never occurred to me.

Here's my analysis referring to a standard HO-3.

There would likely be no coverage under the Liability section. The injured person would have to prove that somebody else's negligence caused him to choke on what he was eating. I don't see that happening.

However, the policy also has a section called Medical Payments to Others. Let's see if that works. Take out your Homeowners Policy and read along with me in the coverage booklet. You'll know it's the right place because it's about 24 pages, give or take.

The first page contains Definitions.

"Bodily injury" means bodily harm, sickness or disease, including required care, loss of services and death that results.

Looks like we do have a "bodily injury."

"Occurrence" means an accident, including continuous or repeated exposure to substantially the same general harmful conditions, which results, during the policy period, in:
a. "Bodily injury";

Looks like we have an "occurrence."

Now find Coverage F - Medical Payments to Others. It's in the latter part of the policy, around Page 17 or so.

We will pay the necessary medical expenses that are incurred or medically ascertained within three years from the date of an accident causing "bodily injury". Medical expenses means reasonable charges for medical, surgical, x-ray, dental, ambulance, hospital, professional nursing and prosthetic devices. Medical expenses do not include expenses for funeral services. This coverage does not apply to you or regular residents of your household except "residence employees". As to others, this coverage applies only:
1. To a person on the "insured location" with the permission of an "insured"

So far, guest's injury appears to qualify.. And the ensuing exclusions don't appear to apply.

I'm leaning toward a yes for coverage under Medical Payments.

Comments?

 

[fed up]

Of course the injury sustained when he hit the table on the way down, or the negligent damage you caused to his windpipe when you cleared the airway, the fact that you knew of the food allergy when making the meal which caused the phobia of ever eating away from home again would all be covered. Plus the damage to his clothing caused by the food coming back up AND the car accident he was involved in on the way home caused by the turmoil in his life by you. Sounds like policy limits any way you look at it

 

[adjusterjack]

Perhaps it wasn't clear to you that I was limiting my question to Medical Payments coverage as it pertains to the choking on the food.

In case anybody else is wondering, let me clear up that point.

I am limiting my question to Medical Payment coverage as it pertains to the choking on the food.

 

[scagnt83]

Did the homeowner provide the turkey or did someone else bring it? If they didnt, what does it say about items brought into the home temporarily by others who are not the homeowner?

Also, the term "necessary medical expenses" could certainly be a potential issue in this. What the individual feels is necessary and what the insurer deems necessary are often different in the medical claims world.

If there are no obvious medical issues, but they just want to "make sure", it very well could be denied, especially if nothing is found to be wrong.

 

[adjusterjack]

Did the homeowner provide the turkey or did someone else bring it? If they didnt, what does it say about items brought into the home temporarily by others who are not the homeowner?

That's edging towards a liability issue which does not apply to Medical Payments, a no-fault type of coverage.

Also, the term "necessary medical expenses" could certainly be a potential issue in this. What the individual feels is necessary and what the insurer deems necessary are often different in the medical claims world.

If there are no obvious medical issues, but they just want to "make sure", it very well could be denied, especially if nothing is found to be wrong.

Medical Payments coverage is not based on the results of testing and shouldn't be. Medical issues are often not obvious. Brain damage due to hypoxia would not be obvious but would be of concern based on the incident even if testing ultimately found no evidence of brain damage.

Medical Payments claims are more liberally evaluated than medical insurance claims.

 

[scagnt83]

That's edging towards a liability issue which does not apply to Medical Payments, a no-fault type of coverage.

Wouldnt the homeowner need to be liable in the first place for the medical payments to kick in?

 

[scagnt83]

Medical Payments coverage is not based on the results of testing and shouldn't be. Medical issues are often not obvious. Brain damage due to hypoxia would not be obvious but would be of concern based on the incident even if testing ultimately found no evidence of brain damage.

Medical Payments claims are more liberally evaluated than medical insurance claims.

I never said its based on results of testing. I said it must be deemed "reasonable & necessary" to be covered.

So the resulting "injury" is the deciding factor here.

Was the person having issues afterwards that would lead a "reasonable" person to seek medical care?

If so, then it should most likely be covered, along with any subsequent recommendations for care or procedures that the doctor gives.

---

When I said "especially if nothing is found to be wrong" only meant that if the Insurer is leaning towards "not reasonable & necessary" .... and they see that the tests showed no issues... it only reinforces their position.

But if the tests do show issues. Its close to impossible for the insurer to say it was not needed.

 

[Allen Trent]

Will depend on if carrier merely wants to pay the medical payments to others. Most, if not all states have laws in place that don't allow a person to sue a layperson for rendering first aid.

So, considering Medical Payments to others coverage is generally only being offered in hopes to eliminate a larger liability lawsuit, I would say carrier wouldn't be paying.

Plus, what would stop any other medical or bodily function incident/event happening at the residence from being covered like a guest injecting insulin & hitting a vein, a guest wiping their rear end & hemorrhoid causing the guest with a bleeding problem to bleed out, etc, etc.

PS. What kind of A-hole sues a family or friend that 1- invited you to Thanksgiving 2- saved your life

 

[adjusterjack]

Wouldnt the homeowner need to be liable in the first place for the medical payments to kick in?

No. Liability has nothing to do with Medical Payments coverage. Medical Payments are paid regardless of fault.

I never said its based on results of testing. I said it must be deemed "reasonable & necessary" to be covered.

So the resulting "injury" is the deciding factor here.

Was the person having issues afterwards that would lead a "reasonable" person to seek medical care?

If so, then it should most likely be covered, along with any subsequent recommendations for care or procedures that the doctor gives.

I disagree. The incident alone should be the deciding factor. Let me try a parallel with medical insurance. I walk into my living room and suddenly get dizzy and lose my balance. As luck would have it I fall into my recliner, no injuries. The room spins for a few minutes then clears up and I'm fine. I go to the doctor, the doctor runs tests, doesn't find anything wrong with me. Will the medical insurance company deny the medical bills because the tests were negative? Of course not. And neither will Medical Payments.

Will depend on if carrier merely wants to pay the medical payments to others.

Not the carrier's choice. The coverage is there.

Most, if not all states have laws in place that don't allow a person to sue a layperson for rendering first aid.

That's a liability issue. Not relevant to Medical Payments.

So, considering Medical Payments to others coverage is generally only being offered in hopes to eliminate a larger liability lawsuit, I would say carrier wouldn't be paying.

That may have been the intent (avoid lawsuits) long, long ago but doesn't apply today in sue-happy America.

Plus, what would stop any other medical or bodily function incident/event happening at the residence from being covered like a guest injecting insulin & hitting a vein, a guest wiping their rear end & hemorrhoid causing the guest with a bleeding problem to bleed out, etc, etc.

That's the kind of discussion I'm looking for. I'm sure that it wasn't the intent of the insurance industry to provide Medical Payments for those incidents but they do appear to meet the definitions of "bodily injury" and "occurrence."