Insurance Bad Faith

April 12, 2019

May Is Mental Health Awareness Month

Mental Health Awareness Month has been observed in May in the United States since 1949 by Presidential proclamation. Each year millions of Americans face the reality of living with a mental condition. According to the National Institute for Mental Health, an estimated 26.2 percent of Americans ages 18 and older—about one in four adults—suffer from a diagnosable mental illness in any given year. Not only are these adults affected by one mental illness; 45% of these adults meet criteria for two or more disorders.

Mental illness is a real and treatable set of conditions that includes major depression, bipolar disorder, eating disorders, panic attacks, generalized anxiety disorder, attention deficit hyperactivity disorder, and schizophrenia, among dozens of others. These disorders are serious enough to significantly impact a person’s daily life functioning, whether at school, work or in their relationships with others.

Among children, ADHD, behavior problems, anxiety, and depression are the most commonly diagnosed mental disorders. According to The Journal of Pediatrics, 2018,

February 13, 2019

The Insurance Representative Says the Treatment is Covered. But is It?

by Kantor & Kantor LLP

During an office visit with your doctor, she recommends you undergo a treatment you’ve never had before. You call your health insurance company, and a representative assures you the treatment is covered by your health insurance plan. Can you rely on what the representative says? Will the treatment be covered by your insurance?

Caution is Key

Be cautious when relying on what health insurance representatives tell you over the phone. The representative can give you general information about what services are covered by your health insurance, but she cannot guarantee that you have met all the requirements under the terms of your policy for the treatment to be covered for you.

February 11, 2019

Is Life Insurance Policy Lapse the end of the story? Maybe not! … [or, “What is the Notice Prejudice Rule?”]

by Kantor & Kantor LLP

Maybe you’ve heard (or experienced) the tragic story of someone becoming ill, forgetting or being unable to pay their life insurance premium, only to see the policy lapse at the time it is needed most. It’s more common than you may realize, and at our law firm we see it quite often. It is terribly unfortunate.

What most people don’t realize, however, is that there is law in California that may come to the rescue. That law is known as the “notice prejudice” rule. The rule emanates from a judicially created doctrine dating back to at least 1963, when the California Supreme Court decided Campbell v. Allstate Ins. Co. (1963) 60 Cal.2d 303, 305. The rule is simple: it prohibits insurers from denying insurance benefits on the ground that the insured presented an untimely claim, unless the insurer can show it was prejudiced by the delay. It is expressly designed to prohibit insurance companies from disclaiming liability based on a “technical escape hatch,” and to protect insureds from the unfair forfeiture of their benefits on procedural grounds. (The rule is also widespread; the majority of states impose a similar requirement on insurers.)

So, how does the rule apply to lapsed life insurance? Well, it is important to state at the outset that it only applies in certain circumstances. One of the most common examples is when the life insurance policy also includes a provision that premium payments will be excused or “waived” in the event the insured becomes disabled. This is usually referred to as a “life waiver of premium provision” (LWOP) or something similar. Many policies have such provisions but policyholders just aren’t aware of the benefit.

March 22, 2018

Insurance Company Doctors Don’t Review Medical Records Before Denying Health Insurance Claims? Are You Kidding Me?

by KantorLaw

California Department of Insurance Commissioner Dave Jones has opened an investigation into allegations that health insurer, Aetna, denies insureds’ claims and requests for prior authorization for medical care without ever reviewing medical records. Although Aetna’s improper utilization review practices come as no surprise to the attorneys at our office, this revelation has sparked widespread, national media attention.

The allegations giving rise to Commissioner Jones’ investigation into Aetna’s claims handling practices come from videotaped deposition testimony of Dr. Jay Ken Iinuma who served as medical director for Aetna’s Southern California business operations between March 2012 and February 2015. During the deposition, Dr. Iinuma said he was following Aetna’s training when he never once looked at patients’ medical records himself before denying their claims for coverage.

Dr. Iinuma’s deposition was taken as part of a lawsuit filed by a college student, Gillen Washington, who was denied coverage for an infusion of intravenous immunoglobin (IVIG) when he was 19 to treat a rare auto-immune disorder. Washington sued Aetna in Orange County Superior Court for breach of contract and bad faith, alleging that Aetna’s “reckless withholding of benefits almost killed him.” Aetna initially paid for Washington’s treatments (each fusion can cost up to $20,000) but when Washington asked Aetna to pre-authorize a November 2014 infusion, Aetna said it was obligated to review Washington’s medical records. Aetna claims that Washington’s treating provider failed to timely provide medical records in response to Aetna’s pre-authorization review. Washington counters Aetna’s narrative of the events surrounding Washington’s ongoing requests and medical need for IVIG treatment. However, it was during Dr. Iinuma’s deposition, where the real bombshell in the case was revealed. The former Aetna medical director testified that he never read Washington’s medical records and knew nothing about the disorder Washington was suffering from despite denying Washington’s pre-authorization request and signing the denial letter. Dr. Iinuma further testified that most of his work was done online and he would rarely if ever consult with an Aetna nurse about a particular claim prior to denying it.

March 16, 2018

When Insurance Companies Don’t Help, They Do Harm

by KantorLaw

In a story that’s far too common, Montreal writer Samuel Archibald recently shared his story of what he called “abandonment by his insurer.” While away from work on leave to treat his depression, Archibald was unknowingly tracked on social media by his insurance company – and everyday simple information about his life was used against him to deny his health claim. Out for a run? He must not be depressed. Eating a meal with family? He must not be depressed. Or at least these are the hasty judgments that his insurer made about his mental health. Did they take into account that exercise can be a wonderful natural anti-depressant? Did they take into account that eating is necessary to survive, and spending time with family can be a healthy part of treatment and recovery? Were they even medically trained to make this type of conclusion, and if so, is it ethical to make this type of conclusion without actually treating a patient in person? The questions go on and on, and in Archibald’s outrage, he took pen to paper and brought light to a very complicated issue in the insurance world. If their job is to help people when they are sick and in need, why are they so often leaving people hanging? Why are they causing harm?

Insurance companies have a bad reputation for paying health claims, and here’s why – they have a long history of denying claims and leaving people in the dark. Leaving people confused. Leaving people in financial distress. Leaving people to suffer without the support they are entitled to.

So what’s the reasoning behind all the denials? The insurer has a bottom line – and unfortunately the bottom line is not your health and wellness. “It’s an insurance company that administers the plan, that decides on the claim, and ultimately has to foot the bill if the benefit is granted – and that’s a conflict of interest that everyone can easily see,” said Sean M. Anderson, a University of Illinois expert in employee benefit plan policy and regulation.

February 16, 2018

Caution when dealing with your insurance company: If you can’t prove it, it never happened!

by Kantor & Kantor LLP

Okay, that headline is a simplification, and maybe even an overstatement, but that’s the attitude of insurance companies, and even courts, when looking at evidence related to life, health and disability claims.

At Kantor & Kantor, one of the most common complaints we hear from prospective clients goes something like this: “When I called the insurance company, they told me to do xxxxxx. So I did xxxxxx. But then they sent me a letter denying my claim/cancelling my coverage because I didn’t do yyyyyy, as the policy required.”

Unfortunately, no matter how much we want to believe the prospective client, our answer is almost always the same: you have to understand, and act as though someone will one day soon say to you, “if you can’t prove it, it never happened.”

December 1, 2017

Is Oral Argument Dying?

by Kantor & Kantor LLP

When you think of what lawyers do for a living, the first thing you probably think of is arguing over a case in front of a judge.

You may be surprised to learn, then, that in the federal courts this staple of practicing law seems to be on the way out. The federal district courts – the trial courts of the federal system – are increasingly holding fewer and fewer oral arguments. Some district courts even have a standing default rule that they won’t hear oral argument on a motion unless the presiding judge explicitly asks for it.

This trend is even more accentuated in the federal circuit courts – the appellate courts of the federal system. While the Supreme Court of the United States holds oral argument in almost all of its cases, the circuit courts of appeal do not.

November 20, 2017

What’s a “Church Plan” when evaluating your right to benefits under employer benefit plan?

by Kantor & Kantor LLP

As you know, churches occupy a special place in the law. For example, the First Amendment bars the government from prohibiting the free exercise of religion, and churches, indeed almost all religioous institutions, get special tax treatment from the IRS.

However, you may not know that this distinction can also affect your employee benefits. Almost all employee benefits are governed by a federal law called ERISA (the Employee Retirement Income Security Act of 1974). This law provides various protections, including imposing a fiduciary duty on your employer to act in your best interests in administering your benefits.

However, if you are a beneficiary of an employee benefit plan established by a church (or other religious organization), your benefits are not governed by ERISA, because ERISA has an exemption for “church plans.” (There is also an exemption for government plans.) As a result, you may lose protections under ERISA if you are a church employee.

June 16, 2017

Tips for Talking to a Lawyer

by Kantor & Kantor LLP

There may come a time in your life when you will need to consult with a lawyer – whether it be good news or bad news. We routinely speak with individuals who have had life, health, and disability claims denied by their insurance companies. Understandably, this is a very difficult time for the individuals who call us. We understand that, and try to make the process simple…but we need your help.

As lawyers, we are well-versed in the practice of law, but we rely on the information from our clients to steer us in the right direction and guide each case. It takes TEAMWORK to get a successful outcome for our clients.

Here are a few tips for talking to your lawyer and sharing with them what they need to know.

May 12, 2017

Just Because An Insurance Company Denies Your Life, Disability or Health Insurance Claim, DOES NOT MEAN YOU SHOULD GIVE UP!

by Kantor & Kantor LLP

For over 25 years, I have been representing individuals who have had life, health, and disability claims denied by their insurance companies. I have represented over 3,000 people. What is so disheartening to me is that I hear from clients again and again that they “almost gave up before calling” me. They tell me they were beaten down by the process, convinced their insurance company must be right, or that they didn’t know there were lawyers who specialized in handling their kind of case on a contingent basis. While sometimes the client HAS waited too long for us to help them, usually my law firm, Kantor & Kantor, is able to step in and successfully resolve their claim.

However, I wonder just how many DO give up unnecessarily. While my view of the insurance industry may appear very cynical, I am 100% convinced that the industry employs a strategy of denying as many claims as possible in the hope that claimants will just give up and go away. I could write pages upon pages of stories about clients who had almost given up, but for whom we were able to obtain benefits with nothing more than a well written letter. It sometimes seems like the insurance company is daring their insured to challenge the denial, or to get a lawyer. If they do, the insurance company will reconsider its denial. If not, the denial will stand and the insurance company will keep the benefits which are rightfully yours.

In the last month, I have obtained over a $1,000,000 in total benefits for several clients who separately told me that they had seriously considered giving up before calling my firm. This led to me to come back to a familiar thought, which was to wonder about all the people who did simply give up. I decided to write this blog in the hope that maybe ONE insured might read it, and decide not to give up. I am not writing this to get business. I have more than I need. I practice in California, but this blog might be read by someone in Florida, or Illinois, or New Jersey, for example. If it is, and you were considering giving up trying to get your benefits, I am not suggesting you call me. Go on the internet, or call your State Bar, and find an experienced attorney in your State. The worst thing that happens, is that no one will take your case — but what if they will?