Insurance and Injury Count

[SymS]

Most (All?) insurance policies have a limit per injury, but what do they consider to be different injuries?

 

The reason I ask is that my wife got a knee operation a few weeks ago, and after a week or so, she had to be admitted again due to a blood clot in her lung (pulmonary embolism). She is OK now and should be released from hospital in couple of days, but It looks like our insurance consider it to be the same injury (knee operation and blood clot) since the latter is likely to related to the former. Is that normal?

 

Also what happens if you break one leg and one arm during a single accident, is that consider one or two injuries since it affects different parts of the body?

Thanks.

 

[Sheryl]

All insurance policies have limits, though some are per event whereas others are annual. Those that are annual will usually have higher caps.

 

Your  second question is easier than the first.

 

For the second - one, since it is the same accident.

 

The usual term in policies is "event" not "illness/injury". An "event" is an accident or the onset of illness or  (if coverage is in-patient only) hospitalization.

 

For the first - if she had developed the blood clot while in still in hospital it would definitely be considered all part of one event. As she was apparently discharged and then re-admitted, it is something of a grey area. I can understand the insurance company's position but one could argue that there is no proof that the embolism was due to the knee injury.

 

Only matters if expenses exceed the maximum per event.

 

Check your policy documents, there should be a list if defitinitions.