When the Insurer argues that the Master Policy is between them and Your employer


#1

Great West throughout our claim has always taken the view that the employer is the policyholder and my spouse is a third party-employee. Therefore they have taken the position that somehow he has less rights as a group Insured than the employer

How we have argued and how we approach this position.

When my husband entered into the contract of employment there was also a standing offer from Great West for all employees to obtain Insurance benefits. Also under all provincial Insurance Acts there is a right of the group Insured to make a claim under his own name.

The employer only negotiates the contract and provisions.

This view may not work out for ASO contracts


#2

From a legal perspective, this situation is governed by basic contract law principles – one of the most interesting courses in first year law school is contracts because the principles come from old cases which are really interesting.

You are caught by the rule call “privity of contract”, which states that only parties to a contract can have rights rights and obligations under that contract. This is basically what the insurer is telling you…however…group insurance contracts are recognized as a “special situation” because the whole purpose of the contract IS TO GIVE RIGHTS AND OBLIGATIONS to a third set of people, who are technically not a party to the contract (the group members). This is why legislators have stepped in some provinces to pass statutes and regulations that over-ride the doctrine of privity of contract in Group Insurance Cases.

However, I believe that even in a province where such statutes and regulations don’t exist, I believe there judge would be very open to the idea of finding a common law exception because of the special nature of group insurance contracts. However, most judges will simply say this is something the elected members of the provincial legislature should do. Really that is where the change must happen for this problem to be solved.

I can never get a case on this issue to court, because once I get involved they just send the Master Policy thereby taking away the grounds for the court motion.


Requesting Claim File?
#3

Great West is defending the bad faith claim against them that my spouse was not owed an implied duty of good faith or fair dealing by them.

I am not feeling that will fly far. It can also be seen as an admission.

The Lawyer for Great West and the Lawyer for two providers are certainly using a chaos strategy against my spouse.

We are using shock and awe in response. That said, the stats for self represented show a 85-95% chance of failure, which we are very aware of.
We may need to pull in a lawyer if we lose the first motions. Confident but not naive that a lawyer adds value. We just have limited funds which I want to use if it goes to examinations.