Articles Posted in Insurance claims and lawsuits

An estimated 3.1 million adults (1.3%) in the United States have been diagnosed with inflammatory bowel disease (IBD), which includes Crohn’s disease and ulcerative colitis. It is a broad term that indicates chronic inflammation of the gastrointestinal tract.

Crohn’s & Colitis Awareness Week was created in 2011 by U.S. Senate Resolution 199, “A resolution supporting the goals and ideals of Crohn’s & Colitis Awareness Week, December 1-7.” Crohn’s & Colitis Awareness Week is designed to bring together the IBD community around a shared goal—to raise awareness and educate the public about IBD.

What is IBD?

Wildfire
Wildfires have decimated swaths of California, leaving entire cities destroyed in their wake.  Many of the homeowners affected by these fires have found too late that they were dramatically underinsured and cannot rebuild or buy a similar home. In essence, their insurance is useless to them.

The Department of Insurance is aware of the problem and issued regulations designed to combat underinsurance – regulations that the insurance industry fought all the way to the California Supreme Court. In 2017, the California Supreme Court upheld the Department of Insurance’s regulation, Section 2695.183, which seeks to hold insurance companies more accountable for providing accurate estimates of replacement cost. That regulation states that an insurance company can breach the implied covenant of good faith and fair dealing when the company chooses to provide an estimate of replacement cost without ensuring that the information on which it relies is accurate and updated.

It is no secret that the wildfires of the past decade have illuminated a huge problem with underinsurance in California.  Since 2017, courts have slowly been reviewing, and ruling upon, claims against insurance companies for failing to fully insure homes, leaving their insureds unable to rebuild or buy a similar home to the one they lost.  To date, only one California state court has evaluated how 2695.183 affects an insurance company’s obligations when insuring a home, and it provides valuable insight into what an insured needs to do if she wants to be protected in the event of the loss of her home.

Very

Medical records are an extremely important source of evidence in your disability claim. The records provide proof of the symptoms that disable you; they provide evidence of your treating provider’s opinion about your condition; and they provide proof of the period of time for which you have been disabled.

Beware

On August 23, 2021 Kantor & Kantor, LLP filed a complaint against Blue Shield of California in the Superior Court for the State of California, County of Los Angeles alleging Breach of Contract, Breach of the Implied Covenant of Good Faith and Fair Dealing, and violation of California Civil Code Section 3428.

After a routine mammogram in 2013, and a subsequent biopsy, Kantor & Kantor’s client, a 59-year old woman, was advised her risk of developing breast cancer was higher than the general population based on the presence of the papillomatous tissue. Upon being advised that she would be a good candidate for one stage breast reconstruction, plaintiff underwent a bilateral mastectomy with bilateral breast reconstruction in February of 2014.

In 2019 the plaintiff contacted her surgeon reporting chronic pain over the chest wall and into her back, despite physical therapy. Plaintiff reported that the pain had gotten consistently worse over a few years and was limiting her activity and causing daily pain.

Lipedema is a condition that causes excess fat to accumulate in the lower part of the body. Lipedema most often involves the buttocks, thighs, and calves. The upper arms can also be affected. The condition does not affect the hands or feet. It can also lead to debilitating symptoms if left untreated, including chronic pain and the inability to walk or move around easily.

What Causes Lipedema?

The exact cause of lipedema is unknown. But the condition runs in families and may be inherited. The condition occurs almost exclusively in women, and usually starts or gets worse at the time of puberty, pregnancy, or menopause. Because of this, there is likely a connection to hormones. Lipedema is not caused by obesity but more than half of patients with this condition are overweight or obese.

The internet provides patients with the resources to locate healthcare providers anywhere in the world. But whether your health insurance pay benefits for treatment with a health care provider anywhere in the world is another issue. Patients are often unhappily surprised when they discover that their health insurance policy limits them to healthcare only within their state or within the health insurance company’s network of providers.

The first step to understanding your health insurance coverage is requesting a copy of the policy. The policy dictates your healthcare coverage. Review your policy to learn whether your policy provides benefits if you go out of state, or out of the country, or see an out-of-network provider for treatment.

If the policy limits you to in-network or in-state benefits and you find a healthcare provider that is perfect for your needs, don’t lose hope. If you can show that there is no in-network or in-state health provider appropriate to treat you, you have a good argument for asking for out-of-network or out-of-state coverage even if the policy only approves in-network or in-state providers. The best argument will demonstrate that there are no in-network providers willing to take new patients or it is outside of their area of expertise. This argument will require through research through many telephone calls to in-network providers to determine whether they will accept the patient. Similarly with out-of-state providers, the argument requires research to demonstrate that there are no in-state providers available.

With the massive increase in wildfires throughout California, the Department of Insurance has adopted what is now an annual tradition of ordering insurance companies to refrain from policy cancellations and non-renewals in wildfire areas.  This year is no exception. On August 19, 2021, the Department of Insurance issued a one-year moratorium on cancellations or non-renewals of fire policies in the areas affected by the Lava and Beckwourth Complex fires.  More than 26,000 homes are affected, in Siskiyou, Lassen and Plumas counties.  This area was already included in last year’s moratorium, but this new order buys those policyholders another year.

Commissioner Lara’s office has stated that he intends to issue a similar moratorium for the Dixie and Caldor fires, once the perimeters of those fires are better established. The Dixie fire is currently only 35% contained. The Caldor fire is currently not at all contained.

These moratoriums are temporary respites from the insurance industry’s practice of non-renewing homes that are in wildfire areas. For homeowners who do lose their insurance because of their location, the “option of last resort” is the California FAIR Plan. This plan offers bare-bones coverage for fire coverage only.  The Department of Insurance ordered FAIR Plan to offer personal property coverage and liability coverage as well in 2019. The insurance industry has been fighting that, and in July 2021 a California superior court ordered FAIR Plan to comply.  Where FAIR Plan will likely appeal that decision, the ability to access this expanded coverage may not actually happen for some time to come.

I want to preface this blog post by saying that I do not have a long-term disability. However, for 16 years of my life, I suffered a life-threatening illness –an illness that I was told that I would either a) die from or b) never fully recover from. Time and time again during those 16 years, I was told to give up hope for any semblance of a normal life, or just resign to dying prematurely. For 16 years, I believed that I should not have hope and there came a point in my journey when I finally gave up all hope and I resigned myself to dying. As fate would have it, on the very same day that I had resigned myself to dying, I ended up having life-changing encounters with human beings who inspired me to fight back and begin the journey to reclaim my hope. Reclaiming my hope was not easy, to say the least. It took me two long and arduous years to reclaim my health and to restore hope, overcoming the odds that were stacked against me. One of those odds was my insurance company –it had told me time and again that I was not sick enough to have my medically necessary treatment covered by insurance. Those two years of fighting for myself, fighting back against the mental defeat I felt because of insurance telling me that I didn’t deserve benefits, during those two years, there were times when it was incredibly hard to hang on to any semblance of hope. I had to remind myself that, “Hope exists. If for no other reason than the Dictionary says it’s a word.”

After I fully healed from the illness, I took my newfound hope and went on to serve as Policy Director on Capitol Hill for a small non-profit dedicated the illness that I had once suffered. In that role, I advocated to raise awareness of that disease, and to get a Federal Bill passed on behalf of people suffering that disease. Once again, the odds were not stacked in my favor. I ended up spending over 10 years advocating with that tiny non-profit on Capitol Hill. During that time, I lost more people to the disease than I can count (meaning, they died), and I heard from people all across the country who had lost loved ones to that disease. Trust me when I say, despite my faith in God, it was not always easy to remain hopeful –I admit that, at times, my hopeful spirit dimmed. But finally, in December 2016, provisions from the bill passed. That day in December was one of jubilation…and yet of humble quiet. The passage of the bill was subdued because it was long-overdue and long-awaited for 16 years, especially by the family after whose daughter the bill was named. The bill was named after Anna Westin who died in 2000 after insurance denied benefits for her treatment.

On ‘the Hill,’ I learned many things. One of the most eye-opening things I learned was: No matter how worthy the cause, the odds are stacked against you if you want to get a bill passed. In fact, in 2016, out of the 12,000+ pieces of legislation that were introduced, only 3% (three percent) passed/were enacted into law.

Here at Kantor & Kantor, we like to refresh and give updates to certain parts of the process we use to help individuals. We feel that the more people understand their insurance benefits, the better they will be able to fight when benefits are denied. Long-term disability (LTD) insurance is a large part of this process, so we will explain the basics here.

Long-term disability insurance is an insurance policy that protects an employee from loss of income in the event that he or she is unable to work due to illness, injury, or accident for a long period of time.

LTD can provide benefits for work-related accidents or injuries that are covered by Workers’ Compensation insurance, but there usually will be an offset, where the LTD benefit is reduced dollar-for-dollar by the amount of Workers’ Compensation payment. LTD also does cover an employee in the event of a personal accident such as a car accident or a fall.

One of the most crucial pieces of evidence in supporting a long term disability claim is the opinion of the claimant’s treating physician that he or she is disabled.

Many physicians are more than happy to assist their patients with forms required by the LTD provider and in some cases, narrative accounts of their patient’s disabling condition.

Sometimes, though, even with the support of your physician, problems can still arise. Often, this is because of the office visit notes your physician makes with each of your visits. Phrases such as, “doing well,” “symptoms improved,” “responding well to medication,” while meant as shorthand by the doctor that her treatment plan is working, are often used by the insurance company to conclude that you are no longer disabled.

Contact Information