California Insurance Lawyer Blog

According to a new report issued by independent research group The Commonwealth Fund, baby-boomers in particular will benefit from the new healthcare reform law, the Affordable Care Act of 2010. See http://thehill.com/blogs/healthwatch/health-reform-implementation/133501-report-boomers-will-benefit-from-reform-law.

“About 95 percent of 8.6 million uninsured adults ages 50-64 will benefit either from expanded Medicaid coverage, the ability to buy subsidized private insurance through new insurance exchanges or new consumer protections, the report said. Further, about 9.7 million older adults who have health insurance but cannot afford out-of-pocket costs will gain improved coverage through benefit standards, limits on out-of-pocket spending and the elimination of lifetime benefit limits,” reported The Hill.

The fund’s study was released only days before a Virginia federal judge ruled that a key part of the reform legislation – the requirement that all Americans purchase health insurance by 2014 – is unconstitutional. Specifically, the court ruled that a mandate to purchase insurance violates the Commerce Clause because it compels an individual to involuntarily enter the stream of commerce. Two other federal courts had previously ruled that the provision did not violate the constitution. As most experts predicted, the U.S. Supreme Court must now decide which court is correct.

To view the entire Commonwealth Fund report, go to http://thehill.com/images/stories/blogs/commonwealth%20boomers.pdf.

The California Department of Insurance (DOI) has frozen a $120 million dividend PacifiCare planned to pay its parent company UnitedHealth Group, explaining that the DOI would rather the money remain in California while it investigates hundreds of consumer complaints about improper claims handling. PacifiCare is charged with nearly 1 million violations, and may have to pay either $5,000 or $10,000 per violation.

“Nobody knows what the outcome of the enforcement action will be, but it is entirely possible that allowing United to siphon off $120 million would enable them to turn penalties into profits. My order simply requires that the company keep the money where it would be available to satisfy any order that is issued,” said California Insurance Commissioner Steve Poizner in a press release.

For more information, log on to http://insurance.ca.gov/0400-news/0100-press-releases/2010/release141-10.cfm.

Kantor & Kantor, LLP -- We help get insurance claims paid.

Anorexia risk may be genetic, reports a new study in Molecular Psychology. The study was the largest ever conducted to look for genetic markers for anorexia and found both variations in gene sequences and in segments of DNA either duplicated or deleted. Study researcher Dr. Hakon Hakonarson, director of the Center for Applied Genomics at The Children’s Hospital of Philadelphia, and his colleagues scanned the genomes of 1,003 people with anorexia (whose average age was 27), and compared them with the genomes of 3,733 children (whose average age was 13) who did not have anorexia. The researchers found a few spots along the genome where the two groups differed and determined these “single-nucleotide polymorphisms (SNPs) could play a role in the genetic underpinnings of anorexia. See “Anorexia Risk May Be Determined by Genetics,” http://www.msnbc.msn.com/id/40325171/ns/health-mental_health/.

A recently published study in the American Academy of Pediatrics Journal reports an alarming trend of children as young as 10 turning to internet chat rooms to learn weight loss or purging methods that can exacerbate anorexia and bulimia. Rebecka Peebles, who authored the study, is urging parents to gain greater awareness about how such unmonitored, interactive sites could affect the health of their teens and pre-teens. The report also addresses how the medical profession’s emphasis on treating obesity in children and adolescents may have placed an unhealthy emphasis on weight loss and dieting. The report documents an increase in cases of anorexia and bulimia among pre-teens, males and minorities during the past decade. Although a full report is not available online, the AAP has posted a policy statement about Identifying and Treating Eating Disorders at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/1/204.

Anyone touched by or concerned with eating disorder issues should also be aware of the valuable resources provided by the International Association of Eating Disorders Professionals Foundation (IAEDP). Check out their website: http://www.iaedp.com/

California workers with employer-provided health insurance endured a 41 percent rate increase during the last six years, reports the Los Angeles Times, citing a recently released Commonwealth Fund study. See “Costs for Employer-Based Health Insurance Soar.” The national increase was 34 percent. The study arrives at time when many employers are also shifting more insurance costs to employees or dropping health care coverage altogether. Health premiums are rising faster than wages, and small businesses are the most severely impacted, noted the report. To review the study, click here: http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2010/Dec/State-Trends-Premiums-and-Deductibles.aspx

Paying for health insurance is hard enough. Unfortunately, getting the claims paid can often be even harder. If you have problems with major healthcare claims, call us. We can help.

If you make a claim for short-term disability (STD) benefits, and your STD claim is denied, and your policy says that the receipt of STD benefits is a pre-requisite to receiving long-term disability (LTD) benefits, you may still have to make a separate LTD claim. If the Policy isn't clear, or if you can't figure it out, go ahead and make the LTD claim anyway. The downside is that it may cause some additional delay. The upside is that the insurance company may fail to properly consider your LTD claim or may make some other mistakes that will help you, should you need to initiate a lawsuit to recover benefits.

In all events, it is critical that you read your policy to understand the procedures involved in making STD and LTD claims, and appealing any and all denials before you can file a lawsuit. Under ERISA, which is the federal law governing group insurance (provided by your employer), you must exhaust your administrative remedies (meaning you must make/submit all claims and appeals spelled out in the policy) before you can file a lawsuit. If you fail to make a claim on time, or fail to appeal a denial, you may lose all rights to pursue legal action. Make sure you READ the policy and make every effort to submit your claim(s) and appeal(s) IN WRITING on time, to protect your rights.

If all this is confusing, or if you are in the midst of an insurance company battle, call us, we might be able to help. We don't charge for basic consultations, and we like to help people.

800-446-7529

If you work for a company, no matter how small, you MAY have disability insurance that will pay a portion of your salary should you become unable to work.

If you don't already know, you should ask your employer whether you have such coverage as it may come in handy in a time of need. If covered, you should request a copy of your short-term disability (STD) and/or long-term disability (LTD) Policy. You never know when you’ll need it.

Once you get a copy of the policy, review it and note some of these important provisions:

* Is there a pre-existing condition limitation?

If your disability policy contains a pre-existing limitation, and you leave work on disability prior to satisfying the required period, you likely will not be eligible for disability coverage. For example, if you saw a doctor in the months prior to being covered through your employment, you may not satisfy the pre-ex limitation. Sometimes, even if you did not see a doctor for months prior to being covered, if you took medication of any kind, you may be precluded from disability coverage.

Often, if you do have a pre-existing condition, you have to be insured for a year and a day before the policy goes into effect. Even if you leave work on disability on day 364 of your employment, with a proven serious and disabling condition, an insurer can deny you on the basis of your not having satisfied the pre-ex condition.

* What are the deadlines spelled out in the policy for making a claim, submitting an appeal, filing a lawsuit?

Thousands of people, dealing with their disabilities, may not realize that they are required to follow certain deadlines spelled out in their policies. Failure to follow these deadlines can mean your claim will not be considered, or will be summarily denied for failure to timely submit it, regardless of the reality and proof of your disability. Deadlines are often spelled out in terms of 45, 60, 90, or 180 days. PAY ATTENTION to these deadlines, as they are critical, and if you fail to meet them, you may lose all rights you otherwise would have had under the policy.

Too often people miss these deadlines by days or weeks. Even with life insurance policies, just because you may be a listed beneficiary, doesn’t mean you can’t lose your right to benefits if enough time passes. For example, if 1, 5 or 10 years go by before you make a claim for life insurance proceeds, it may be too late. These benefits aren’t necessarily guaranteed, so stay on top of claim deadlines in all insurance policies.

* How do private disability benefits work with state benefits, social security benefits and worker’s compensation benefits?

Remember, STD and LTD benefits, whether provided through your employer, or through a private policy, are independent of California state (EDD) benefits, social security benefits and worker’s compensation benefits. Just because you may have made a claim for California state disability benefits, and you receive the full year of these benefits (these benefits are limited to one year only), this does not prevent you from filing for private STD/LTD benefits. In fact, it is easy to reason that once the state benefits run out, and you’ll need a source of income, then you can make a claim for private STD/LTD benefits. It does not work this way, however, and you will miss the deadline for applying for private benefits, and lose all benefits you may have been entitled to, if you wait too long. The same is true with social security disability insurance benefits–just because you may have applied for them, or are receiving them, is no guarantee that your private insurance benefits will be paid. As for worker’s compensation benefits, these come into play if you became sick or injured on the job, and we urge you to seek the assistance of a worker’s compensation attorney who will work with you and your employer to resolve this.

The only way that all of these benefits interface, is when your private disability insurance carrier approves your STD/LTD disability claim, it can (and will) offset your private disability benefits with income you receive from other sources, including California state disability benefits, social security disability insurance benefits, and worker’s compensation benefits. Disability insurance policies contain different offset provisions, so it is important that you read this portion of your policy as well. (For example, an insurance company may reserve the right to offset with estimated benefits you’ll receive from the Social Security Administration, even if you do not in fact receive these).

Do explore all options: look into applying for STD, LTD, California state disability, social security disability insurance, and - if applicable - worker’s compensation benefits.

If you have any questions, or would like a free consultation, contact Kantor & Kantor, we can help.