CRC Claims Advocacy Team Challenged Claim Denial and Won

Claim denials are stressful for insureds and can strain their relationships with retail risk advisers. When an insurer denied a recent bodily injury claim, the insured’s broker turned to CRC Group for help. CRC’s Claims Advocacy Team went to work to challenge the claim denial.

The insured, a long-term healthcare facility operator, had filed a claim under healthcare professional liability and general liability policies that CRC had placed, seeking defense coverage from its insurer for a patient’s bodily injury lawsuit. The insurer denied the claim, asserting the alleged injuries were not caused by medical services performed by the insured and saying the GL policy excluded bodily injury claims to patients.

Initially unable to persuade the insurer to reverse its denial, the insured faced a complicated situation: the insurer allowed only 10 days to appeal the decision because it planned to exit healthcare professional liability business. The retail broker’s claims representative told CRC this was a dire situation. “If I explain to the insured that the claim is denied, I will be in hot water. Any suggestions of what I can do next?”

That next step made a big difference for the retail broker and its client. CRC Group’s Chief Claims Officer, David Gilfillan, reviewed the complaint, the insurance policies, the denial letter and correspondence between the insured and its insurer. He quickly contacted the attorney handling claim appeals and immediately obtained a one-week extension to respond to the coverage denial. Next, he retained coverage counsel — at CRC Group’s expense — to assist in drafting an appeal.

The coverage counsel found the healthcare professional liability policy had an amendatory endorsement that defined “medical professional services” to include “an act, error or omission resulting in a violation of a patient’s rights as provided by Patients’ Rights Laws or Regulations.” In addition, counsel also found regulatory language requiring facilities such as the insured’s to ensure that residents “can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.”

Formally submitting the appeal, which included the citations the coverage counsel had discovered, CRC Group was notified within weeks that the insurer would withdraw the claim denial and provide a defense to the insured, subject to a reservation of rights.

Collaborating with CRC Group and the CRC Claims Advocacy Team, the retail broker and its client turned a frustrating situation into a favorable outcome. Claims advocacy is another way of showing CRC Group is about “placing you first.”