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Suppose the contract or booklet is ambiguous or unclear?
The law generally provides that the plain meaning of an insurance policy, plan or evidence of coverage governs its meaning and construction. The policy or plan must be read as a whole in order to determine the reasonable meaning of the terms and the intent of the parties, and be consistent with the intended goal of the insurance or plan. If, a policy or plan term is ambiguous, or there is a conflict between terms in the policy and/or evidence of coverage the law generally provides that the policy or plan language should be construed in favor of the insured or member and against the insurer or plan.
In addition to consulting both the policy or plan and the applicable evidence of coverage document, determination of what a coverage or benefit is requires, as to any particular coverage or benefit, a reading of all applicable "definitions," "benefits," "limitations," and "exclusions" contained in the policy or plan and the evidence of coverage. |
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