Caught lie and deception by insurer

Disability Insurance
1

Hello

In this post I am describing an attempt of my insurance company to put me in breach of contract, and how I got an admission of having been lied to. I will first provide a short introduction then provide a slightly longer summary.

My former claim manager has lied to me in writing about sending me a form. Her lie would have put me in breach of contract.
Upon my escalation of the issue to the insurance company, I was left a voice message by a insurance employee confirming that my former claim manager did not send me the form.

Below I will list the steps involved in the deception. The thing to keep in mind is that I have a contractual obligation to return any completed Form within 30 days of request.

CHRONOLOGICAL EXPLANATION:

On June x my former claim manager emails me that at some future time I will be contacted by my future claim manager, who will be asking for “current information” for my file. (My former claim manager will keep reinforcing this expectation of future requests by a “still to return to the office” future claim manager several times.)

On June y I email both my former and my future claim manager that my doctor is on vacation, and that my next doctor’s visit is in x days, being already booked for July. I ask my future claim manager to wait to send me any Forms until July. (My former claim manager is being copied on this email.)

On June x, 31 days before my doctor’s visit, my former claim manager emails me implying that she had already sent me a Form for my doctor. Her email is deceptive: it is intentionally written so as to imply she has sent me the form, but craftily composed so as to make me overlook/ gloss over her statements implying that she has already sent me the form.

How is my former claim manager deceptive? By three strategies:
-by starting her email with another reminder of my future claim manager still having to return to office
-by burying the implications that the insurer is waiting for the completed Form in the middle of long paragraphs
-by conveying those buried implications as if they are just descriptions of the claim process in general, and not referring to an actual request having been made
(If I had glossed over her statements, by the time I would have seen my doctor I would already have been in breach of contract.)

On June x I email my former claim manager asking her to confirm that she did not sent the form yet. She emails back that she did send the form already, but that she is attaching it “again”, for my reference.

I escalate to the insurance company and state that the former claim manager’s statement that she had sent me a form before June x has put me in breach in contract. I also state I have not received any such form.

I am left a voice message by a insurance employee (from the “Consumer” team) confirming that, according to their investigation, the Form had not been sent, on or before the date the claim manager wrote she did send the form.

Concluding:

First of all I would like to know what is it that my Insurer just attempted to do? Is there a technical term? (Bad faith?)
What do I do now? What type of lawyer should I approach?
What can I hope to achieve by involving a lawyer?
I understand there might be a limitation period on these things?
So what are my next steps?

Thank you.
Alecs

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Hi alecs, based on my experience insurance companies are God in Canada. That’s because the Government gave them all kinds of power. Some will say your former claim manager made a mistake and everyone makes mistakes. A similar issue happened to me a few years ago. I just had to keep calling my claim manager and have them send another form. I hope this helps.

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Alecs,

Insurance companies and their employees are not allowed to engage in deceptive practices with people they insure. An insurance company has a contractual obligation to act in good faith and lying about sending forms etc would be a clear violation of that principle.

This appears to be a situation of a claims person trying to cover their “butt” because they may have not followed their internal protocols, etc. This happens sometimes, so I am not surprised by your story.

On a technical point, are you sure there is contractual deadline for you to provide forms back within 30 days. That would be very unusual for a group policy to be that specific. Usually, the rule is that you must respond within a reasonable time (which is often interpreted as 30 days), but would certainly be extended in a situation like you describe. So, I question if you were ever actually in breach of the policy, even if the insurance claim representative presented it to you as such.

The type of legal claim can arise in situations involving deceptive practices would be that of bad faith as you describe. It would be a legal claim for bad faith damages, also called punitive damages. There is a long history in Canada of courts providing these types of damages and this area of the law is now well developed. That means we have a good idea of when courts will award these types of damages to a person.

The limitation period on bad faith claims is usually 1-2 years from the date of discovery, but you would need to get a specific legal opinion based on your situation.

You would need to seek out a disability lawyer or lawyer dealing with insurance claims for this type of case.

Based on the facts you describe, I don’t see this as a situation where a court would award punitive damages against the insurer (but I say this in general without knowing all the facts – you would ned to get a specific legal opinion before making any decisions). The Insurer did an internal investigation when you brought this to their attention, and informed you that the claims rep had lied to you. Your benefits were never terminated based on this deceptive practice. This seems more like an issue of a rogue employee, as opposed to an widespread scheme pushed from higher up in the organization. I expect that claims rep is going to be disciplined very harshly, possibly fired, if the facts are as you say.

David Brannen

Disability Lawyer with Resolute Legal

The response posted above is based on the limited factual information made available and is not intended as a full and complete response to the question. The only reliable manner to obtain complete and adequate legal advice is to consult with a lawyer, fully explain your situation, and allow the lawyer enough time to research the applicable law and facts required to give an adequate opinion. The basic information provided above is intended as a public service only, a full one-on-one discussion with a lawyer should be done before taking any any action. The information posted on this forum is available to the viewing public and is not intended to create a lawyer client relationship with any person. If you want one-on-one advice, please click here to request a free consultation or call toll free 1-877-282-5188 to speak with a member with our disability claim support team.

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Hello David

Thanks for the reply.

Yes, the contract specifically states “must be returned within 30 days from request”.

I have 2 questions:

Suppose that one can prove on the balance of probabilities that there was intent. Even if the employee was “rogue” would not the insurer be responsible for that?

My second question is very important because I am lacking the “know-how”: how would one approach a lawyer dealing in bad faith damages: would one just ask for a consultation, or would one also provide more information up-front, such as, for example attach the 6 point chronological explanation I posted at the start of this thread?
I am asking this because I wish to start on the right foot.

Many Thanks.

Regards, Alecs

5

Hi Alecs,

I will do my best to answer your questions:

  1. Yes, insurance companies can held responsible for the conduct of their employees.

  2. When you approach lawyers they will have questions and you can give them the overview you provided here. The key points are that the claims manager lied to you about sending the form and threatened to cut off payments. Payments were never actually cut off. You went above the claims manager and complained to the insurance company. The insurer investigated your complaint and confirmed the claims manager was lying.

It is important to understand that it is very rare for a court to award punitive damages against an insurance company. Courts will always examine the context and in the case you describe, lying did happen, but benefits were not ever stopped and the insurance company did an investigation at your request and confirmed the claims manager lied to you. I don’t see this as a situation where a court would award punitive damages. The insurance company did the right thing in investigating and reporting back to you. I expect this claims manager was disciplined. On the other hand, if the company had tried to cover this up, didn’t do an investigation, also lied to you about the results of that investigation, etc, then it would rise to the level where a court would want to punish the insurance company.

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Hi David.

Thank you for the clarification.

Regards, Alecs

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