Articles Posted in Health Insurance

The effect of COVID-19 on the lives of every American cannot be overstated.  What we cannot know yet is how those effects will continue into the future.  We buy insurance to protect us in the event of future calamities. A variety of different types of insurance could potentially be triggered by the varying effects of the disease.  As it can be hard to know what the future could hold, the points below summarize the different ways your insurance could be involved in COVID-19 repercussions in the months and even years ahead.

It is difficult to know with certainty the range of long term health issues that could be caused by COVID-19, as the virus has only plagued us for approximately six months. Doctors predict the long-term effects will be similar to other coronaviruses like SARS.  While 80% of sick patients had “mild” cases, of the 20% who did not, they could experience a variety of long term effects.  COVID-19 survivors are expected  to follow the path of severe respiratory issues often seen after recovery from other respiratory illnesses.  That could mean lung fibrosis, reduced lung capacity and difficulty breathing and fatigue. Preliminary data out of China demonstrates that 20% of patients hospitalized with COVID-19 had heart damage. Patients also experience increased blood clotting.  Early studies from Asia show that COVID-19 attacks T-cells in a manner similar to HIV. Doctors are also finding that close to half of those hospitalized for COVID-19 have blood or protein in their urine, which is an early indicator of kidney damage, and up to 30% of patients in New York and Wuhan lost some level of kidney function. Liver damage, intestinal damage, and neurological malfunctions have also been reported.

Health Insurance

An employee who becomes disabled while covered by an employer-sponsored disability plan may qualify for short-term disability (STD) benefits and then long-term disability (LTD) benefits, based on the length of the disability and the terms of the plan. However, some LTD policies require that the employee not only apply for STD, but “exhaust” it, meaning receive the maximum amount of benefits allowed under the policy, before they may pursue LTD. If an employee received all but one day of the full STD benefit, they may still have to go through the appeals process or risk eligibility for the more valuable LTD benefit.

Kantor & Kantor was recently retained by a client, who we will refer to as John Smith for anonymity.  Mr. Smith was employed by a large corporation as a Material Handler who was responsible for all supplies and materials needed to manufacture medical devices.  Unfortunately, he became disabled by degenerative disc disease and painful spondylosis of his lumbar spine.  In addition, he suffered from sciatic nerve pain in his back.  His painful conditions necessitated medications which also caused side effects and impacted his functioning.

Mr. Smith’s company’s disability plan claim involved the situation described above, except that his STD claim was terminated just a few weeks before he received the maximum duration of benefits.  He unsuccessfully appealed his STD denial on his own before hiring the law firm.  In evaluating his STD claim and his potential LTD claim, the attorneys identified the following language in his LTD policy:

Obviously, the coronavirus pandemic has affected everyone to some degree, and that includes the insurance industry and the people who rely on insurance to protect themselves from disaster.

Fortunately, the California Department of Insurance has been active in an effort to protect policyholders who are affected by the pandemic. As we already reported, on March 30 the DOI directed health insurance companies to increase access to services delivered via telehealth during the current state of emergency.

On April 3, the DOI took even more significant action. It issued another notice, this time directed at all insurers doing business in California, regarding claim deadlines. The DOI instructed all insurance companies to stop enforcing policy or statutory deadlines on policyholders for claims or coverage until 90 days after the COVID-19 state of emergency has ended.

Millions of Americans have lost jobs — and often the health coverage that came with those jobs. Millions of Americans had their work hours reduced or have received drastic pay cuts, so monthly premiums that may have been manageable before are now out of reach. It is important to understand your options and take action right away, so you don’t have gaps in health insurance coverage.

First, find out when your coverage is ending. You may have coverage until the end of the month you’re laid off or longer, depending on your employer. After your employer’s coverage ends, you can usually continue your employer’s coverage (but pay much higher premiums) or buy a policy on your own. Your best choice depends on each policy’s premiums, coverage, provider network – and what medical needs you and/or your family members have.

Here are some things to consider when evaluating your options.

On April 8, 2020 Kantor & Kantor Partner Elizabeth Hopkins and Karen L. Handorf of Cohen Milstein, filed a friend-of-the court brief in the Supreme Court for Phyllis Borzi and Dan Maguire, two former, high-ranking Department of Labor officials.

The brief supports a number of States that successfully challenged a newly-enacted federal regulation, which runs contrary to the requirement in the Affordable Care Act (ACA) that women in healthcare plans be provided free access to preventive health services.

Under the challenged regulation, virtually any employer may simply disregard the ACA requirement that healthcare plans provide cost-free contraception for women enrolled in such plans, and thereby prevent enrolled women from receiving this congressionally-mandated preventive health service.

On March 30, 2020, California Insurance Commissioner Ricardo Lara and the California Department of Insurance (“CDI”) directed health insurance companies to increase access to services delivered via telehealth during the COVID-19 state of emergency.

The agency said that increasing the availability of telehealth will “lessen the strain on the supply chain, reduce the need to use scarce stocks of provider personal protective equipment and protect the ability of the healthcare workforce to provide care by limiting physical exposure to potential sources of infectious disease,” the notice states.

To support expanded telehealth, CDI said insurers should allow all network providers to use all available modes of virtual care delivery, including video and telephone-based communication. Insurers are also required to reimburse telehealth services costs at the same rate as in-person office visits, effective March 30, 2020.

In addition to dealing with short term disability benefits, long term disability benefits, and health insurance denials, many of our clients are also tasked with keeping track of changes to their Social Security benefits. Here are some of the changes that will take effect on January 1, 2020 for Social Security recipients –

  • Social Security recipients will get a 1.6 percent cost-of-living adjustment (COLA) in their monthly benefits starting in January. The average individual retired Social Security beneficiary is expected to see a monthly benefit jump from $1,479 to $1,503, an increase of roughly $24 per month or $288 for the year.
  • As a result of the COLA, the maximum monthly benefit a single recipient can get also will grow. That benefit will increase from $2,861 per month in 2019 to $3,011 per month in 2020.

In his October 28, 2109 Opinion piece published by The Philadelphia Inquirer, Ross Waetzman opened with this harrowing sentence, “I almost died because of insurance prior authorization rules.” His story went on to share the details of how he nearly died as a result of the decision made by his insurer, Independence Blue Cross (“IBC” or “IBX”), to deny authorization of benefits for a test that had been recommended by Mr. Waetzman’s cardiologist.

The test Mr. Waetzman’s cardiologist had recommended was a cardiac catheterization. The test was necessary because Mr. Waetzman’s history of chest pain had been increasing in intensity, despite lifestyle changes he had made in an attempt to curb his symptoms. The cardiac catheterization was recommended by Mr. Waetzman’s cardiologist after less-invasive tests had been performed. Those less invasive tests, an EKG and a coronary calcium test, revealed that Mr. Waetzman was in the top 10% for his age and race for calcium deposits on his coronary arteries. With such deposits known to result in reduced blood flow to the heart, the cardiac catheterization was recommended to determine if Mr. Waetzman’s chest pain was a result of a blocked artery.

Unfortunately, when Mr. Waetzman’s cardiologist, Dr. Kenneth Mendel, called IBX, he was informed that “prior-authorization” for the cardiac catheterization was denied. IBX claimed that Mr. Waetzman did not meet all the necessary criteria to have the test and his only available option was to appeal the denial.

As we continue to learn about efforts to challenge proton therapy denials by groups such as the Proton Therapy Law Coalition, the fundamental question becomes: Will the insurers actually get the message and change their ways? A recent article suggests that even when a jury awards a large punitive damages figure against a health insurer, the carrier is likely not truly getting the message.

In November 2018, an Oklahoma jury returned a $25.5 million verdict against Aetna for improperly denying coverage for proton beam therapy, a treatment the company considered experimental. In the largest verdict for bad faith in U.S. history, the jury found that Aetna “recklessly disregarded its duty to deal fairly and act in good faith” and awarded punitive damages. During the course of deliberations, the jury specifically discussed “sending a message” to Aetna and “making a statement” so Aetna would reevaluate how it handles appeals and requests for coverage.

However, many large insurance companies, if state allows them to, carry their own liability insurance for just this occasion. It appears that about 20 states do not allow insurers to carry such liability coverage. But insurers are now turning to products sold by offshore insurers beyond the reach of state regulators. In other words, a lot of insurers are not directly paying for the punitive damages awarded against them. This undermines the importance and impact of large jury verdicts on effectuating changed insurer practices.

Breast-Cancer-Awareness
According to the Centers for Disease Control and Prevention (“CDC”), breast cancer is the second most common cancer among women in the United States.

  • In 2019, an estimated 268,600 new cases of invasive breast cancer will be diagnosed in women in the U.S. as well as 62,930 new cases of non-invasive (in situ) breast cancer.
  • Men also get breast cancer, but it is not very common. Less than 1% of breast cancers occur in men.
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