Imagine that you have just spent some time visiting with your family and their kids, and shortly after they leave your house you trip on a toy and fall. For one Colorado woman, that was the beginning of a nightmare that she is still dealing with.
There is no law against an adult having a couple of glasses of wine in their own home. But for a Loveland Colorado woman, that decision may have cost her tens of thousands of dollars in medical bills that her insurance is refusing to cover.
In something right out of a John Grisham novel, an insurance company is refusing to pay for over fifty thousand dollars worth of medical bills after a woman tripped and fell on one of her grandkids toys.
Carol Mullins had been visiting with family at her her home in Loveland, and during the evening consumed a few glasses of wine. Virtually every part of this story sounds like something we have all done many times. But shortly after her family had left, she accidentally tripped and fell over one of her grand kid’s toys. In fact she fell so hard that she needed to be rushed to the emergency room by ambulance.
Once at the hospital, doctors determined that the fifty five year old woman had seriously fractured her skull, and the resulting surgery and associated costs wound up running to over fifty four thousand dollars.
This should not have been a problem, except that her insurance company, Tokio Marine HCC, found a tiny loophole that they are exploiting to avoid paying her bills.
During her exam, the hospital indicated that she had elevated blood alcohol levels. And this is where the story gets really ugly. Tokio Marine HCC points to a sub clause in her policy that states that “Injury sustained that is due wholly or partially to the effects of intoxication or drugs is excluded under this policy.”
Ms. Mullins says “These insurance companies, they take and take and take and as soon as you have a claim, ‘sorry can’t help you’. I’m 100 percent sure I would not have fallen if the sled would not have been there.”
She goes on to say that “I wanted to throw up because I couldn’t believe it because I knew we were in the $50,000s (of medical bills).” and finally makes the point ““I was in my own home. I wasn’t out driving. Since when can’t you have a couple of glasses of wine in your own home?”
Attorneys for Tokio Marine HCC spoke with local news media about the case, stating that the “policy speaks for itself.” However, he did suggest that she file an appeal.
Also speaking to local news, Vincent Plymell of Colorado’s Division of Insurance suggested that she file a complaint with the Department of Regulatory Agencies, as his office has never heard of such an exclusion.
Plymell said that while it may be legal for an HMO to deny such a claim on these grounds, he was not aware of one ever doing so. He also said that it was not clear if Tokio Marine HCC qualifies as an HMO in the state of Colorado.
Have you ever had a health insurance claim denied? How did you fight it and did you win? Please share your stories with us here.