WARNING: AUTO INSURANCE LOOPHOLE

Birthday-Easter2013 102If you think your auto insurance policy protects you from financial loss, you could be in for a very unpleasant and expensive surprise.  A gigantic loophole makes it possible for insurers to sidestep their responsibility.  If an accident is determined to be caused by a  “medical emergency,” the responsible driver’s insurance company can declare itself not liable for damages caused– both medical and property damage.

A few days ago I walked into the house at the end of the day to be greeted by a letter from ESIS, Inc., an insurance company representing the driver of the car that struck mine January 14.  Naively, I thought it might be information about when they would begin payments toward the medical bills that have been coming in weekly. (Bills for just the first surgery topped $16,000.)  I was disappointed.

In part, the letter read:

Our investigation has concluded that our account driver suffered a medical emergency at the time of this loss. We have determined that he did not suffer from a pre-existing condition and could not have foreseen that this would occur. This was an unfortunate incident; however we fail to see the negligence or liability on our account driver. This incident was caused by a sudden medical emergency that could not have been prevented. Therefore, we must respectfully deny your claim for damages.

While I have the greatest sympathy for the other driver and his medical problem, which would likely be difficult to verify because of health privacy laws, it all seems a little too convenient.  Of course the driver and his insurance company are not morally culpable, but it seems absurd that there should be no financial responsibility for his insurer.  I’m sure he has been paying the same kind of high insurance premiums I have.  And I suspect he wouldn’t be overjoyed to hear that his insurance will not cover damage caused by his medical emergency.

From the beginning my insurer, State Farm, has been quick to react.  Eight days after the accident I was issued a check for replacement value of an eight month-old car that was a total loss. The picture above shows the remains.  The amount was perfectly fair. I’m sure they felt confident that State Farm would be reimbursed eventually. Now, that doesn’t seem likely.  They have been reassuring and efficient about medical expenses, but their maximum responsibility has already been reached long before any determination of how much more treatment I might need– a third surgery and/or physical therapy are not out of the question.

And I can’t help being concerned for the driver of the car behind me who was hit head-on, destroying her car and, I suspect, injuring her at least as much as I was.  Did she have adequate insurance?  I don’t know. With the random nature of our health insurance system in the United States, does she have any medical coverage?

I feel no anger toward the driver who came across the median and into oncoming traffic.  Most likely, he was injured more seriously than I.  Sympathy seems more appropriate.  But, like a lot of legal points, this one is beyond me and leaves me feeling very uncertain.  If this insurance company has no financial responsibility, what other fine points of insurance coverage don’t they tell us about ahead of time?  Do we have more surprises before this is settled?  And with all the insurance we carry, how much financial exposure is just impossible to avoid?

If you are injured by a driver who is experiencing a medical emergency: a heart attack, a stroke, a seizure, and probably any number of other emergencies we can’t predict or imagine, you may be out of luck.  At the very least, check your insurance policy and be absolutely certain that you have uninsured and under-insured motorist coverage.

Bill Morgan

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