A regional retail company provided Medical Insurance for its staff, under policy managed by the Lynch Employee Benefits department.
One of the Client’s staff members underwent a medical procedure not typically covered under the standard Medical Insurance policy, which led to significant complications requiring an urgent transplant. The Insurer declined approval for the transplant since the initial procedure was not a covered risk under the Medical Insurance policy.
The Lynch team immediately reviewed the case given the necessity of the transplant. Even though the initial procedure was not a covered risk under the Medical Insurance policy, the contract’s wording was vague with regard to consequential complications, and Lynch challenged the decision. Lynch maintained that while a claim could not be made to cover the cost of the first procedure, one could be made for the complications, and urged approval be given for the hospital to perform the transplant.
The Insurance Company disputed Lynch’s argument and International Legal Advisors were engaged; ultimately it was established that Lynch was indeed correct and that resultant complications were not excluded from cover. The Insured received the necessary transplant under cover of the medical policy.
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