I have had an accident policy for many years with Aflac thru my employer. Recently (5 wks) ago, I went to the doctor because I had a pain in my foot which was getting worse. I was diagnosed with a Jones fracture for which I received a cast on my foot and leg preventing me from working. I applied to Aflac for benefits on my accident policy since I didn't break my foot on purpose and don't even know how it happened. After about 3 weeks, Aflac sent me a denial letter, saying "After carefully reviewing the claim, we have determined that benefits are not payable for the following reason (s):
The Emergency Room Benefit is payable only if the injury requires treatment within 72 hours after the accident." I did not go to the Emergency Room, I went to my doctor. My doctor sent me to the hospital for x-rays. Then I was sent to the orthopedist, all in the same day.
My Aflac policy says, under Part 1, Definitions:
(F) Fracture:
A break in a bone that can be seen by x-ray. It must be diagnosed as a fracture by a Physician within 14 days after the date of the accident. (My pain started June 30, my doctor's appointment was July 8.) The fracture must require correction by a Physician. It can be corrected by open or closed reduction.
In Part 4, Uniform Provisions:
(G) Notice of Claim:
Written notice of claim must be given within 20 days after a covered loss starts or as soon thereafter as is reasonably possible. The notice can be given to us at AFLAC New York or to your agent. Notice of claim should include the name of the covered person and the policy number.
(I) Proof Of Loss:
Written proof of loss must be furnished to AFLAC New York, at its home office, within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate or reduce any claim if it was not reasonably possible to give proof within such time. However, such proof must be furnished as soon thereafter as is reasonably possible and in no event (except in the absence of legal capacity) later than one year from the time proof is otherwise required.
I also sent an email to my company rep, Henry Dunn, requesting him to contact me regarding my policy. That was 3 business days ago and I have heard nothing.
My feeling is that I have done business with them for years and should be treated as tho my policy has meaning.
0 comments