California Insurance Lawyer Blog

On April 12, 2011, Kantor & Kantor partner, Lisa Kantor was one of five speakers in a Congressional Briefing in Washington D.C., entitled “Addressing Eating Disorders Through the Federal Response to Eliminate Eating Disorders Act.” This Briefing was sponsored by The Eating Disorders Coalition in cooperation with Senator Tom Harkin (D-IA).

The "FREED" Act is the first comprehensive eating disorders bill in the history of Congress that provides needed action for research, treatment, education and prevention of eating disorders. The Act recognizes that eating disorders are serious and life threatening, but that with adequate and appropriate treatment people do and can recover. That Act also requires research, education and prevention so that we can better understand, treat, prevent, diagnosis and intervene early with eating disorders patients.

Click here to read Ms. Kantor’s speech.

We recently obtained a Judgment against Anthem Blue Cross regarding its refusal to pay for 2 weeks of inpatient treatment for our client who struggled with an eating disorder. The client, a middle-aged woman, sought treatment for her anorexia nervosa at Pacific Shores Hospital, in Oxnard, California. Her health insurer, Anthem Blue Cross, agreed to pay for the first part of the doctor prescribed treatment, but then cut off benefits before the treatment program was complete. Anthem informed her of its denial on March 19, with a retroactive denial date of March 11. Since her doctors advised her to complete the program they had set for her, our client paid out of pocket for her last 2 weeks of treatment.

Our client successfully completed her stay at Pacific Shores Hospital and went home, equipped with strategies learned during her five-week-long treatment, to maintain a healthy body weight and image. She continues to be conscientious in her recovery and has returned to her active life and hobbies, including horse-back riding. Her case is an example of how focused treatment for eating disorders, uninterrupted by insurance claims denials, can be highly effective.

The California Association for Health Services at Home (CAHSAH) is the leading statewide home care association in the nation and the voice of home care for the western United States. CAHSAH represents more than 537 members and 850 offices that are direct providers of health and supportive services and products in the home. Next month, May 10-12 CAHSAH will hold their annual conference in Ontario California.

Kantor & Kantor Partners, Glenn Kantor and Corinne Chandler will have the honor of addressing CAHSAH members during an educational session to speak on issues related to long term care and insurance. The session will take place on Wednesday, May 11, 2011, 10:15:00 AM - 11:45:00 AM.

Mr. Kantor and Ms. Chandler will address the reasons insurance companies deny long-term care benefits. They will also discuss the importance of anticipating denials, understanding the policy language and limitations, having all necessary documentation and support letters to include with the claim, and communicating with the insurer in a manner that will establish a record if appeal or litigation becomes necessary.

Our lawyers are frequently called upon to speak at organizational events and we pride ourselves on being in a position to help people not only understand their health related insurance benefits, but to also help them obtain those benefits when they have been wrongfully denied.

For more information on CAHSAH and the Conference, click here: http://www.cahsah.org/?p=annual_conferences

“Don’t take a health insurer’s rejection as the final word on your medical claim,” writes Tom Murphy of the Associated Press in a recent article about how to craft an appeal to an insurance company to re-evaluate a denial. See “Fighting an Insurance Claim Denial Can Pay Off,” http://www.philly.com/philly/business/personal_finance/20110405_ap_fightinganinsuranceclaimdenialcanpayoff.html?page=1&c=y.

Murphy cites a recent report from the Government Accountability Office that found – in some states – appeals have about a 50 percent success rate. The article lists a number of actions policyholders can take to provide relevant information that could prompt an insurer to change its mind. Those factors include obtaining and submitting copies of your entire medical file; enlisting your doctor to write letters explaining the need for medical care; understanding policy language and complying with all deadlines; and supplying medical literature and scientific studies that support the efficacy of the requested treatment.

That’s all good advice, but what the article fails to mention is the impact of federal law on the appeal. Any information not included in this appeal, which is mandatory before you can file a lawsuit against the insurance company for benefits, usually cannot be introduced in the subsequent lawsuit. Don't just assume you are right and that the insurance company will change their mind. As you can see, at least 50% of the time, they don't. You must be complete and thorough with what you include in the appeal, because you won’t get a second chance. So... do it right the first time.

If you plan to appeal an insurance denial, we can help. Call us at (800) 446-7529.

Most Californians do not know that unlike auto, property and casualty insurance, the Insurance Commissioner does not have the authority to reject excessive health insurance rate hikes. Since 1988, when California voters approved Proposition 103, the Insurance Commissioner has saved California consumers billions of dollars every year in excessive premiums on their auto, property, and casualty policies. Extending these protections to health insurance and managed care plans is long overdue. Assembly Bill 52 gives the Insurance Commissioner the authority to overrule excessive health insurance rate increases and gives the Department of Managed Health Care the authority to reject excessive HMO rate increases. This is one of the pieces missing from the federal health care reform legislation.

This critical piece of legislation is schedule to be heard during this legislative session. The Legislators need to hear from all Californians who are concerned about continually rising health insurance rates. Listed below are the Assemblymembers who sit on the Assembly Health Committee. Please call their office and let them know that the continually rising health insurance rate increases are unsustainable and that you support AB 52.

Assembly Health Committee members:

Bill Monning, Chair (D) -- (916) 319-2027
Dan Logue, Vice Chair (R) -- (916) 319-2003
Tom Ammiano (D) -- (916) 319-2013
Toni Atkins (D) -- (916) 319-2076
Susan Bonilla (D) -- (916) 319-2011
Mike Eng (D) -- (916) 319-2049
Martin Garrick (R) -- (916) 319-2074
Richard Gordon (D) -- (916) 319-2021
Mary Hayashi (D) -- (916) 319-2018
Roger Hernandez (D) -- (916) 319-2057
Bonnie Lowenthal (D) -- (916) 319-2054
Alan Mansoor (R) -- (916) 319-2068
Holly Mitchell (D) -- (916) 319-2047
Brian Nestande (R) -- (916) 319-2064
Richard Pan (D) -- (916) 319-2005
V. Manuel Perez (D) -- (916) 319-2080
Jim Silva (R) -- (916) 319-2067
Cameron Smyth (R) -- (916) 319-2038
Das Williams (D) -- (916) 319-2035

On April 12, Lisa Kantor will join other eating disorder activists in Washington, D.C. to lobby Congress to pass the FREED Act, H.R. 1193, the Federal Response to End Eating Disorders, a comprehensive bill that addresses eating disorder research, treatment, education and prevention. Ms. Kantor, a partner in Kantor & Kantor, will be part of a select group of panelists who will speak to a congressional committee about how U.S. institutions could change attitudes and perceptions to encourage and promote effective treatment of and recovery from eating disorders.

Most notable, Ms. Kantor will testify about insurance and health plan attempts to both construe and limit policy language in ways that deny coverage for treatment in specialized residential facilities. For example, in January some insurers completely eliminated residential treatment as a covered mental health benefit, despite clinical evidence demonstrating that residential treatment is a critical stage of comprehensive and effective treatment for many individuals suffering from eating disorders.

“This is an alarming trend that not only narrows treatment options for people suffering from eating disorders but also could put many facilities out of business,” says Ms. Kantor. “If these health insurers are successful in their attempts to undermine effective treatment for eating disorders, other health plans will follow their dubious leadership. That will life-threatening to many people seeking full recovery.”

Ms. Kantor is among only a few lawyers in the country advocating for insurer reimbursement for clients with eating disorders. She has a number of significant wins for these clients, including cases that have changed the law in California and the 9th Circuit. She is currently working with eating disorder professionals and facilities to determine what actions to take to change the insurance industry’s perception about care for eating disorders and what regulatory, legislative and class action litigation measures are necessary. Ms. Kantor has been a keynote speaker for the International Association of Eating Disorder Professionals and frequently speaks to other groups about health insurance issues and eating disorders. For more information, call (800) 446-7529 or contact Ms. Kantor at lkantor@kantorlaw.net.

For more information about the FREED Act, go to http://www.eatingdisorderscoalition.org/documents/summaryofFREEDAct.pdf.