54-year-old Jey Rupasinghe was an accomplished ophthalmologist, proud husband and father whose family meant everything to him. In order to protect his family financially, he purchased comprehensive health insurance that included a critical illness benefit in the amount of $250,000.
Jey began to experience nausea, fatigue and abdominal cramps on a regular basis. He booked an appointment with his doctor when he realized his symptoms weren’t getting better. A blood exam identified that Jey’s liver was not functioning normally. Further tests helped diagnose Jey’s condition as fatty liver disease. Jey’s doctor told him he needed to make diet and lifestyle changes to reverse this early stage of liver disease.
By age 57, Jey’s condition had unfortunately worsened, even though he had tried his best to follow his doctor’s advice to change his diet, cut out alcohol and exercise. Swelling in his legs and abdomen, weakness and loss of appetite caused him to take a permanent leave from work. He was seeking regular treatment, until one day, his specialist broke the news that Jey’s liver disease was in a late stage and the best prognosis would be from a liver transplant.
Jey was placed on a waiting list with one of the country’s best transplant centres. His wife and children rallied around him. Jey decided it was time to submit a claim for his critical illness benefit so that his family would be able to keep up with their bills and other expenses.
Jey submitted extensive medical information and filled out all the required paperwork the insurance company requested. He survived the 30-day waiting period after the date of diagnosis of major organ failure. Even then, the insurance company’s requests spanned six more weeks and seemed endless. Finally, they wrote back to Jey with a startling response: while they acknowledged that Jey met the criteria for major organ failure, on waiting list, the claim was denied based on Jey’s failure to provide information regarding another health condition he had been suffering from when he took out the insurance.
While Jey did disclose the fact that he suffered from ulcerative colitis, he did not disclose that he sometimes had a loss of feeling or tingling in his limbs or face. Jey didn’t specifically disclose this information because he believed that the insurance company would be aware that people with ulcerative colitis sometimes experience these symptoms. They refused to pay the $250,000 lump sum benefit based on this alleged misrepresentation.
Jey and his wife immediately consulted with Share Lawyers upon receiving this upsetting news from their insurer. Knowing that Share Lawyers would not receive any fees unless they won his case reassured Jey and his wife that the firm would make their best efforts to fight on their behalf.
Although Jey’s policy clearly stated that it would cover the insured upon “major organ failure on waiting list for a transplant”, the insurance company had decided totake the route of challenging Jey’s integrity by asserting that he failed to disclose information in an effort to hide relevant details from the insurance company.
Shortly after Share Lawyers filed Jey’s Statement of Claim, the insurance company’s counsel contacted them to discuss the possibility of reaching an early settlement of the claim. A settlement meeting was arranged and within several months, a favourable settlement had been reached.
Jey did undergo a liver transplant in 2013 and is doing very well today. The settlement of his critical illness claim helped his family to stay afloat financially while he recovered from his transplant surgery until he was able to return to work.
*All names and identifying details have been changed to protect the confidentiality of all involved.