Questions have been raised over why an innocent victim in a shooting apparently was denied a health insurance payout for treatment for his injuries.
Mitchell Anthony Wright, one of two men injured by a single bullet during a shooting in a nightclub parking lot last year, needed surgery on his arm following the incident.
According to a victim impact report presented to the court, he was denied insurance coverage because he was shot. The name of Mr. Wright’s insurance company was not revealed in court.
The financial hardship he suffered as a result was listed as an aggravating factor contributing to the 13-year sentence handed down to shooter Leighton Rankine Jr. last month.
Health insurance experts questioned by the Caymanian Compass said there are no legitimate exclusions in approved health insurance contracts that would prevent a victim of crime from being covered by insurance.
Mervyn Connolly, of the Health Insurance Commission, which settles disputes and appeals related to nonpayment of insurance claims, said it was possible that the payment had been deferred until the conclusion of the court proceedings. He said the commission would now expect the insurer to pay out.
“Where the courts determine that the insured was an innocent victim and a witness as indicated, we would expect the approved insurer to adjudicate the claim accordingly,” he said.
Jeanette Verhoeven, a life and health insurance specialist for insurance broker Aon Risk Solutions, urged the victim to seek a prompt review of his claim with his insurer now that the court case has concluded, or appeal to the Health Insurance Commission.
She said the only exclusions that could legitimately be applied are in the cases of a shooting in which someone was injured in the act of committing a crime, attempted suicide or self-harm, or in the extremely unlikely event of war or terrorism in the Cayman Islands – and only if their policy included such exclusions.
“The insurer will sometimes wait for the full police report, death inquest or trial to finalize the medical or life insurance claims,” she said.
Rankine was sentenced last month for the shooting in the car park outside Club 7 on West Bay Road in February. In passing sentence, Justice Marva McDonald-Bishop said she was taking into account the “physical, psychological, emotional and financial impact” on his victims.
A victim impact statement included testimony from Mr. Wright that his insurance company had refused to pay for his surgery because the incident was a shooting.
There was no suggestion that he was anything other than a victim and his role in the trial was as a witness only. The trial heard that a bullet went through the arm of the first victim, Jolyon Frederick, and then lodged in Mr. Wright’s arm.
Mr. Wright’s evidence that he received no insurance payout for surgery on his injuries appears to have been accepted by the court. There was no suggestion during the hearing that he would be able to receive compensation once the case was concluded.
Mr. Wright was unavailable for comment last week.
Mr. Connolly said insurers had the right to include exemptions for injuries sustained while committing or attempting to commit a crime. He added, “If the insured person is the victim of the assault, then this principle would not apply.”
At the request of the Compass, Ms Verhoeven analyzed sample polices from several insurance companies, including, Aetna BritCay, Cayman First, CayMed Plus, Fidelity and Generali Worldwide. She said none included exemptions when a person was the victim of crime. Many, however, require a police report as evidence and may refuse to pay out if the insured party was deemed to be involved in the act of a crime.
“I would advise this person to promptly ask for their claim to be re-adjudicated. Now this has been settled in court, they can go back to the insurer and say, ‘these are the facts of the case.’ If the insurer does not reprocess the claim, the injured man has the option to go to the HIC and file a written complaint and request for review.”
She said there were certain claims that raised red flags for insurers.
“Dog bites, traffic accidents, gunshot wounds – those are the sort of claims insurance companies are going to look at twice and ask, ‘are we or another party going to be ultimately liable for these medical expenses’?
“In some of these cases, the insurers can seek subrogation, which is a refund of medical payments from a motor or homeowner policy holder who caused the harm.”
She said obtaining these refunds whenever proper and available helped to keep medical premiums lower.
She said anyone who felt they had been unfairly denied a claim should try and work it out with their insurance company or through their broker in the first instance. The ultimate recourse is the Health Insurance Commission.