California Insurance Lawyer Blog

Insurance companies will always assert that you must have "objective evidence" to support your disability claim. Of course, Policies do not always require objective evidence, and even worse, what you or your doctors may consider objective, your insurance company may not. Insurance companies will often try to characterize your evidence as "subjective" or self-reported (and thus, according to them, unreliable.) So, what to do? While it can sometimes be very difficult to muster evidence with certain disabling conditions, there are a range of options to explore that may be available to you.

You can work with your doctor (or her/his staff) to obtain evidence - from the more obvious testing, such as stress tests for the heart; blood tests for a range of other conditions; functional capacity evaluations (FCE) (to assess your capacity to work or function for a given amount of time in a work-simulated environment), or independent medical evaluations (IME) by a doctor separate or 'independent' of your primary doctor or specialist(s). FCEs and IMEs may require referrals or separate payment, depending on your insurance.

Insurers generally deem a doctor's report of your medical history and treatment, or your doctor's clear, articulated notes from clinical observations during your appointments, as the most relevant or compelling evidence of disability. Insurers will often contact your doctor, by phone or in writing, and while we always encourage our clients' doctors to conduct correspondence with insurers in writing, so that nothing is misconstrued or taken out of context, it can be critical for your doctor(s) to participate in the process of accurately and comprehensively documenting your disability, symptoms, side effect of pain medications, etc.

Letters from co-workers, supervisors, or even friends and family describing you and your condition and their personal observations of your troubles are also helpful. Evidence of activities you formerly were engaged in but have now let lapse due to your condition is also worthy of submission.

The point is that you should not overlook anything which is in anyway relevant to your disability claim. Put your best foot forward. If you don't understand something your doctor said or wrote, get clarification. If you do not think your doctor has adequately diagnosed or treated your condition, get a second opinion. DO NOT assume that the insurance company will take what you say at face value. They won't. They are much more likely to discount everything you say, and everything you provide.

If you need help, call us. 800-446-7529.

One of California’s largest health insurers -Blue Shield- has announced plans to hike its premiums by as much as 59%. These increased premiums are set to take effect on March 1, 2011. This move impacts 193,000 individual Blue Shield policy holders.

This steep double digit rate hike has raised the attention of Health and Human Services Secretary Kathleen Sebelius who has reached out to newly elected California Insurance Commissioner Dave Jones. “We stand ready to assist him and the people of California in any way that we can”, she stated. She went on to state, “The people of California have a right to be concerned when they see this kind of rate increase month after month.”

Commissioner Jones recently won a hard fought race for his position and on January 3, 2011 announced that rejecting excessive health insurance premiums and continuing his fight for the authority to reject these premiums are among his main priorities for his time in office. However, as he stated in his inaugural address, “Many Californians will no doubt be surprised to learn that the Insurance Commissioner does not have the legal authority to reject excessive health insurance premium increases.” Unfortunately, despite health reform, even the federal government does not have the authority to review and strike down unreasonable rate increase requests.

Instead, Commissioner Jones has requested that Blue Shield delay implementation of the rate hike so that he and state regulators have the opportunity to fully review the increase. In a statement on January 6, 2011, Jones said, “I find it stunning that Blue Shield would seek to impose such massive premium increases on policyholders during these troubling economic times....[T]hese premium increases will impose significant financial burdens on struggling families and, in some cases, will lead to the loss of health care coverage all together.”

This is just the first fight of many that Commissioner Jones will face with the insurance industry. In his inaugural address, he identified his main objective as “making the California Department of Insurance the strongest consumer protection agency in the nation” and to “set the standard for other consumer protection agencies.” His three main priorities are:

1. To implement federal health care reform and build on that reform by granting the insurance commissioner the authority to reject excessive premium increases;
2. To level the playing field for consumers and business as they deal with insurance companies...to make sure that consumer complaints are being addressed and that insurance companies are not taking advantage of consumers; and
3. Ensuring that California has a viable and competitive insurance market.

To implement his first priority, Commissioner Jones has created a new senior leadership position titled, “Deputy Commissioner for Health Care Policy and Reform.” He will continue the efforts to provide the commissioner and the Department of Managed Care the legal authority reject excessive health care premiums and he will see to it that he has the legal authority to enforce the new federal health care reform. Jones has already signed an emergency regulation giving him the authority to enforce in California, the new federal 80% medical loss ratio for the individual health insurance market. Existing California law requires insurers to spend at least 70% of premiums from the individual market on medical care. Jones’ proposal aligns California’s regulations with the national Medical Loss Ratio rules established under the federal health reform law that took effect on January 1, 2011.

The next four years under Insurance Commissioner Jones promise to be one of the most consumer oriented terms ever in California. It will be a challenge to deal with the special interests of the insurance carriers while working to protect the rights of California’s insureds. But so far, Dave Jones has demonstrated that he is ready to stand up to the insurers and protect consumers.