Articles Posted in Health Insurance

Bipolar Disorder, a brain based disorder, causes unusual shifts in mood, energy, activity levels, as well as the ability to carry out day-to-day tasks (National Institute of Mental Health). Bipolar Disorder is a serious mental illness that affects a great many Americans every year. Kantor & Kantor has worked with many clients who suffer with Bipolar Disorder, and such clients are often affected in a way that is life altering and debilitating. Unfortunately, it is not uncommon for these clients to face many obstacles and complications when making a claim for long term disability benefits (LTD) for Bipolar Disorder.

Why are these Long Term Disability claims so difficult?

The first issue that can arise is difficulty in proving that you are disabled (under the terms of your long term disability policy’s definition of disabled).  While you and your doctor both know that you are no longer able to work, meeting a policy definition of disability takes more than just that knowledge.  Unlike a back condition or an autoimmune disease, which can be shown through objective measures, objectively establishing that you have disabling Bipolar Disorder can be tricky. Typically, the diagnosis is made by a therapeutic psychologist. The condition is then treated medically by a prescribing psychiatrist, as well as through therapy with a clinical psychologist.  Thus, there really is no lab test or other objective measure to prove you have the condition.  Your treating providers’ diagnosis, based on their examination and treatment of you, is the objective proof – but you must have their help in getting that information to your LTD carrier.

At the time of the denial, it is customary for claim representatives to tell insureds that they will have an opportunity to appeal the denial and that the appeal will be a “fresh look” at the evidence in the file.  Recently, we here at Kantor & Kantor have seen a new trend with some insurance carriers when there has been an initial denial of benefits.  Some carriers are now providing insureds with a one or two page “appeal form” to be completed by the insured for the appeal.  This is misleading and may actually prejudice the insured when completing the appeal.

As discussed in other posts on this website, the appeal to the insurance company is perhaps the most important part of a claim prior filing a lawsuit.  It is the only opportunity for an insured to ensure that all of the evidence supporting his or her claim is in the insurer’s claim file.  As such, an insured needs to include all medical records and testing documenting his or her impairments. If it is not included within the insurer’s claim file at the time of the final denial of the claim, it is very difficult, if not impossible to persuade a trial judge to consider the evidence.   Thus, the mere completion of an appeal form, without the additional documentation, may cause an insured to believe that a few sentences, “explaining” the disability, may cause an insurance company to overturn its decision.  In truth, it will not.   The insurance company will deny the claim on appeal and its claim file will be incomplete, without the evidence that should be included to prove disability.

The insured should not be misled into believing that completion of a simple form will be sufficient to overturn the decision on appeal. The insurer’s claim file should be obtained to review the evidence in support of the denial and the denial letter should be carefully scrutinized. Once this is done, an appeal should be thoroughly prepared to rebut the insurer’s evidence.

Posted by: Beth A. Davis

If you have a long term disability claim through a policy provided by your employer, ERISA most likely governs that claim. As such, if your claim is denied and you have to pursue your benefits, there are very specific rules and regulations about how – and sometimes whether – you will be able to provide evidence of your disability to the insurer.  Also, the quality of the evidence matters very much.  This blog will give you some pointers on what to gather before you hire an ERISA attorney to assist you with your appeal – and you should definitely hire an ERISA attorney to help you because the appeal is your only opportunity to provide the insurer with the necessary evidence to properly support your claim.

  • Request your claim file – if your claim has been denied, you should request a complete copy of your claim file from your insurer. This will help the attorneys to ascertain whether you have a case they can assist you with and what evidence you will need to support your claim;

When we refer clients to the California Department of Insurance (“DOI”) to report problems with their insurance company’s handling of health claims, it may seem like a wasted effort. After all, the DOI is a large state agency and our clients are just individual patients. A new decision by the California Supreme Court shows that the DOI represents the interests of consumers on a large scale and, even more, the DOI has the power to fine insurance companies that violate insurance regulations.

The California Supreme Court has upheld the DOI’s right to collect $91 million in fines for UHC’s mishandling of health claims. United Healthcare Group now has the ominous reputation of being the largest health insurer in the country, AND the insurer charged with the largest number of insurance regulation violations ever committed in California state history.

The DOI, like other state departments of insurance, is charged with the duty of overseeing insurance companies to ensure that insureds are being fairly treated and claims are properly paid in accordance with California state insurance regulations. The DOI has the power to apply fines to insurance companies that violate state insurance regulations. The DOI found violations such as denying treatment for people with serious illness and claim payment denials for providers and hospitals. The DOI does not need to show that the insurance company intended to break the law or engaged in a general practice of misconduct. The DOI can apply fines when an insurance company should have known that their actions were in violation of state insurance regulations.

Posted by:  Andrew M. Kantor

Happy 2019! In honor of the New Year, I wanted to take some time to discuss some of the newer developments in the world of Disability Insurance.

Advancements in the Fight to Acknowledge ME/CFS

Today, in our second Mental Health Awareness Month (“MHAM”) blog, we feature a story shown on April 23, 2018, on NBC Nightly News. The story features the Binion family who lost their son Jordan (“Jordy”) to suicide shortly after Jordy declined further treatment for his mental health issues. Unfortunately, even when families desperately want their child to receive treatment, some state’s laws give deference to a minor’s “right to choose.”

Beyond the Binion’s tragic loss, the NBC new piece shared a few very alarming statistics:

  • 40% of states within the U.S. have laws in place that allow minors as young as 12 to affirm or decline consent for mental health treatment;

Insurance is our safety net.

It’s our protection against the unthinkable. Our first line of defense when something goes wrong. Our safeguard for our health and our finances. Our security for our family and our homes. Our precaution against all the “what ifs.” Our surety in protection of our resources and access to healthcare and treatment.

On paper, health insurance sounds pretty anticipative and hopeful. It sounds like if an illness or tragedy were to strike, things would be okay in the end – because someone would be there to catch you. But the harsh reality seems to be a security net with many holes and many flaws. In the hands of insurance companies, so many people seem to be falling through the holes of the net, slipping through the worn out spaces, and some even missing the net completely as they fall.

Each year millions of Americans face the reality of living with a mental illness. May is Mental Health Awareness Month (“MHAM”) and is used to educate and bring awareness to the issue of mental health. During MHAM, Kantor & Kantor will share a series of blogs about various issues and topics related to mental health and highlight important figures and organizations within the mental health community.

We launch our blog series by sharing three short videos featuring The Honorable Patrick J. Kennedy. The Honorable Mr. Kennedy represented Rhode Island’s 1st District in the U.S. House of Representatives from 1995 until 2011. During his congressional tenure, he became one of the nation’s leading voices on mental illness, addiction, and other brain diseases, including he bravely shared about his personal battles with addiction. As a champion to end medical and societal discrimination against all mental illnesses, The Honorable Mr. Kennedy was a lead sponsor of The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”).

Two years after leaving Congress, The Honorable Mr. Kennedy founded The Kennedy Forum, an organization focused on advancing the current ideas, policies, and programming in behavioral health known to be effective, while shining a light on the solutions of the future. To learn more about The Kennedy Forum, please visit: https://www.thekennedyforum.org

Doctor support is critical to patients getting the health benefits they deserve. In health claims, we often see patients who are seeking medication or treatment that is deemed “experimental” or “investigational” by an insurance company, even though other insurance companies may approve the same medication or treatment. The claims that succeed are those that have stellar doctor support. Doctors want to help but need direction. Here are some pointers for patients to get doctor support for health claims.

First, get it in writing. The doctor may have mentioned to you that studies have shown that the recommended treatment is appropriate for your condition. That’s not enough, you need it in writing. Make an appointment with the doctor or his office manager. Explain that you are asking the insurance company to pay for treatment that the doctor has prescribed for you and that you need a letter of support. Most doctors are happy to provide a letter explaining their treatment recommendations.

Second, address the insurance company’s specific concerns. If the insurance company is claiming that the treatment or medication is FDA approved for other conditions, but not your condition, give facts and argument that explain why it is appropriate for your condition. Provide studies (by reference or attach copies) that support your argument. Obtain letters from other patients with the same condition who received benefits for the same treatment.

The Affordable Care Act (often referred to as “Obamacare”) put mental health care on par with physical health, at least as far as health insurance goes.  The reality facing many people in California, however, is that insurance does not automatically mean providers are available. A recent report released by the Healthforce Center at the University of California San Francisco reported the following statistics:

  • Approximately one in six adults in California were diagnosed with a mental illness in 2014, while one in twenty-five had a serious mental illness
  • One in fourteen children in California had a serious emotional disturbance
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