What are my fiancé’s rights if he was in a motorcycle accident and called his insurer to make sure that he had medical coverage and was mistakenly told by the agent that he did?

They told him to go to the ER. While we were there another agent called saying she heard the recording when he called previously and that he actually was not covered. Is there any legal recourse we can take to make them pay for his medical bills?

Asked on August 3, 2015 under Insurance Law, Oklahoma

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 5 years ago | Contributor

If it was the case that he only went to the ER due to the representation or claim that he had coverage, he may be able to force them to pick up the bill: when someone makes a promise or representation to another person, with the intention that the other person rely and act on it, and it is reasonable for that person to rely on the promises or representation, the law may make the promise or representation enforceable under the theory of "promissory estoppel."

The problem is, if your fiance would have had to or should have sought medical attention anyway, whether or not he had coverage, then the statement about his coverage did not cause him to go to the ER and would not be enforceable. So a key issue is whether he needed go to the ER anyway, or whether it was "optional" (given the extent and severity of his injuries) to go and the claim about his coverage was what tipped the balance. Another problem is that if the insurer refuses to pay, to force them to do so, even if you believe that they should, your finance would have to sue them; and bringing a lawsuit has its own costs, in time and money, so depending on the size of the medical bills, it may not be worthwhile doing this.


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