Policy holders in Grand Prairie, Fort Worth, Dallas, Arlington, Irving, Grapevine, Colleyville, Roanoke, Saginaw, Carrollton, and other places in Dallas and Tarrant Counties would need to know the ways a life insurance claim can be denied.
One common reason for denial of a life insurance claim is that the insurance company says there was a misrepresentation made in the application.
The San Antonio Court of Appeals issued an opinion in 1993, that dealt with this issue. The style of the case is, Carmen L. Garcia v. John Hancock Variable Life Insurance Company. Here are some of the facts.
The case is an appeal from a summary judgment in favor of John Hancock. In February or March of 1986, Alfredo Garcia, applied for and was issued a life insurance policy with John Hancock. In two policy applications, Mr. Garcia was asked a series of questions regarding his health history. The first application, dated February 25, 1986, was signed by Mr. Garcia and an agent of John Hancock. On that application, Mr. Garcia represented that he had never been treated for or had any known indication of diabetes. He also represented that he (1) had not consulted a physician or been examined or treated at a hospital or other medical facility within the last five years; (2) was not being treated by a physician or taking any prescription drug; and (3) did not have a personal physician.
The second application, dated March 10, 1986, was signed by Mr. Garcia and a medical examiner pursuant to a physical examination initiated by John Hancock. On this second application, Mr. Garcia again represented he had never been treated for or had any indication of diabetes. He also responded, once again, that he was not under treatment of a doctor or taking any prescription drug. Further, he stated that he had never been treated for or had any indication of dizziness and that he did not smoke cigarettes. Mr. Garcia executed the applications stating “the forgoing statements and answers” are “to the best of my knowledge and belief, complete, true and correctly recorded.”
In February of 1987, Mr. Garcia died from a heart attack. During litigation, Mrs. Garcia candidly admitted that Mr. Garcia had been diagnosed with diabetes in 1970 and had either injected insulin or taken pills daily until 1980, when the disease went into remission. It is undisputed that Mr. Garcia was experiencing dizziness around the time he made representations to the contrary. In fact, he visited a doctor on February 18, 1986 and was taking prescription medicine for diabetes at the time he executed the March 10, 1986 application.
To win the motion for summary judgment, John Hancock had to prove:
1) the making of a representation;
2) the falsity of the representation;
3) reliance on the misrepresentation by the insurer;
4) the intent to deceive on the part of the insured in making the misrepresentation; and 5) the materiality of the misrepresentation.
Here, John Hancock argued two facts they felt were important. Specifically, it contended the fact that Mr. Garcia misrepresented his health on two applications, dated February 25 and March 10 respectively, confirming his intent to deceive because both sets of representations were made within two weeks of each other, with the first being made less than a week after February 18, the date he began taking a prescription drug to treat diabetes.
In overruling the trial court’s grant of the motion for summary judgment, this court said that even if John Hancock’s argument is factually correct, they did not agree it has proven intent to deceive as a matter of law based upon the number, frequency and proximity of the alleged misrepresentations of the medical treatment. Other courts have held that “mere knowledge of one’s health condition is insufficient to prove intent as matter of law.” As said by another court, “the fact that the insurance company proved the insured ‘knew about his health problems and made false statements concerning his problems does not prove as a matter of law that he intended to deceive [the insurance company].'”
This case serves as a great example how an experienced Insurance Law Attorney can help someone who has had life insurance benefits denied.
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