What are my rights if I have a medical issue and my insurance company declined to get allow me to get the correct tests for diagnosis and now I’ve been in an accident because of it?

UPDATED: Sep 30, 2022

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What are my rights if I have a medical issue and my insurance company declined to get allow me to get the correct tests for diagnosis and now I’ve been in an accident because of it?

My fiance has been trouble staying awake during the day and falling asleep driving so on and so forth. She got a sleep study done and they said nothing was wrong, so then when she went to go back to get another study done to confirm narcolepsy, which even her doctor is suspecting is the problem. However, her insurer denied the test. She was just in a traffic accident due to the fact that they keep telling her that there is nothing wrong and can’t get the proper procedures done. Do I have a legal case here?

Asked on August 24, 2016 under Insurance Law, Ohio


SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 6 years ago | Contributor

First, your question says that you have the medical issue and got into the accident, but below that, you write that it is your finance that had the condition and accident. If it was your fiance, then if there is a cause of action, she, not you, would have to assert it: being engaged is not a legal relationship (not like being married, for example) and you can't bring a legal action on your fiance's behalf.
Second, if by your question, you mean can the medical insurer be sued over the accident because they did not let her get the test, etc., the answer is no. Their denial of paying for the test is not sufficiently causally linked to the accident--the chain of causation, from not paying for the test to the accident, is not direct, foreseeable, or strong enough to support liability:
1) She could have gotten the test anyway and paid for it herself: not having your insurer pay does not mean you can't have the test, so they did not cause her to not get tested;
2) Even if she'd had the test or procedure, she still could have had the accident: there is no way to prove or establish that getting the test would have prevented the accident.
3) If she was falling asleep while driving, then test or no test, she should not have driven: driving while she knew she had a problem makes the accident her fault, not anyone else's.

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