A client holds a comprehensive major medical health policy. They undergo a newly developed, FDA-approved outpatient procedure. The insurer denies the resulting claim, arguing the treatment falls outside their internal definition of covered "surgical interventions." However, the policy's actual written definition of surgery is vague and does not explicitly address or exclude this new procedure. If the client challenges this denial in a legal dispute, which of the following describes how the distinctive characteristics of an insurance contract will dictate the outcome?
- Because insurance is a contract of adhesion, any ambiguity in the wording will be strictly construed in favor of the policyholder.Answer
- BBecause the insurer drafted the contract, any ambiguity in the wording will be interpreted in favor of the insurer's original intent.
- CBecause the specific procedure was undefined, the contract lacks valid consideration and the policy must be rescinded.
- DBecause the policyholder did not make a strict warranty about future treatments during the application, the insurer retains the right to deny the claim.
Answer
Because insurance is a contract of adhesion, any ambiguity in the wording will be strictly construed in favor of the policyholder.
Insurance policies are considered contracts of adhesion because the insurer writes the contract entirely without input or negotiation from the insured. Consequently, legal precedent dictates that if the contract contains vague, ambiguous, or poorly defined language, courts will resolve the ambiguity against the drafter (the insurer) and in favor of the policyholder.
Step-by-Step Solution
Key Concept
Contracts of Adhesion and Ambiguity