Articles Tagged with insurance coverage

In 2017, 47,000 Americans died by suicide and 17.3 million adults suffered at least one major depressive episode. When I see statistics like those, my mind floods with a flurry of thoughts all at once:

  • “Why?”
  • “How many more have died by suicide since 2017?”

September is National Recovery Month and is an observance held every September to promote and support new evidence-based treatment and recovery practices, the emergence of a strong proud recovery community, and the dedication of service providers and community members across the nation who make recovery in all its forms possible.

Mental health and substance use disorders affect all communities nationwide, with commitment and support, those impacted can embark on a journey of improved health and overall wellness. The focus of National Recovery Month this September is to celebrate all people that make the journey of recovery possible by embracing the 2021 theme, Recovery is For Everyone: Every Person, Every Family, Every Community.” National Recovery Month spreads the message that people can and do recover every day.

Mental health and substance use disorders affect people from all walks of life and all age groups. These illnesses are common, recurrent, and often serious, but they are treatable, and many people do recover. Mental disorders involve changes in thinking, mood, and/or behavior. These disorders can affect how individuals relate to others and make choices. Reaching a level that can be formally diagnosed often depends on a reduction in a person’s ability to function because of the disorder. For example:

I highly recommend the NPR series, “Bill of the Month,” which offers an expert analysis of medical bill surprises. This month’s bill concerns jaw surgery and a hospital bill of more than $27,000. The patient, Ely Bair, had a condition requiring two jaw surgeries. The first jaw surgery went very well and Bair paid his out of pocket maximum of $3,000 and his employer’s health plan with Premera Blue Cross covered the rest.

Bair’s second jaw surgery was with the same hospital and the health insurer was also Premera. But this time, Bair received a bill of $27,119 from the hospital.

The reason is in the fine print. Although Bair was covered under Premera policies for both surgeries, he changed employers between the two surgeries. Although both employers used Premera, the insurance coverage provided by Premera was different with each employer. The second Premera plan had a lifetime maximum of $5,000 for this jaw surgery. That left Bair responsible for the rest of the hospital bill. When he appealed, Premera pointed him to the specific language in the 80-page policy that addresses the lifetime maximum for this specific surgery.

Because of the number of fires in California over the past several years, there are huge shortages of labor and materials for building homes. It can take well over a year for someone who lost their home in a wildfire to secure a contractor and get permits to be able to build.

The California Department of Insurance knows this. On May 18, 2019, the Insurance Commissioner issued a Notice requiring insurers to extend additional living expense (“ALE”) benefits to as long as 36 months if needed for claims made due to a state emergency such as a wildfire, regardless of any time limit in the policy. “Good cause” is specifically noted to be unavoidable delays in the construction process. This can be delays with obtaining permits, or finding a contractor, or getting materials. It can also be delays due to the pandemic.

Note that this extension does not increase the dollar limit of ALE, if any, in the policy, so if your rebuild is delayed, you want to minimize the monthly cost of your lodging and related expenses to stretch it out as long as possible. This extension only applies to fires that occurred on or after September 21, 2018. However, 29 insurance companies agreed to voluntarily provide this extension to victims of the 2017 wildfires as well.

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.

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.

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.

This Kaiser Health News article highlights the challenges of women attempting to obtain coverage for appropriate birth control options recommended by their physicians.

The article shows how insurance coverage is driven by a chart developed by the FDA for consumer education, not intended to exclude insurance coverage for other types of birth control.

Insurance companies further restrict coverage by limiting options to a list of approved products and requiring patients to given reasons why they cannot use other forms of contraceptive methods before other products will be approved.

The California Fair Access to Insurance Requirements Plan Association or “FAIR Plan” was established by statute in 1968 to meet the needs of California homeowners unable to find insurance in the traditional marketplace. The FAIR Plan is a syndicated fire insurance pool comprised of all insurers licensed to conduct property/casualty business in California. All licensed property/casualty insurers that write basic property insurance required by Insurance Code sections 10091(a) and 10095(a) are members of the FAIR Plan. The FAIR Plan issues policies on behalf of its member companies. Each member company participates in the profits, losses, and expenses of the Plan in direct proportion to its market share of business written in the state.

Wildfires have caused insurmountable destruction in California over the last decade, causing many insurers to pull back from the California fire insurance marketplace. While many Californians have turned to the FAIR Plan for fire risk insurance, the FAIR Plan represents itself to the public as an “insurer of last resort” that provides only “basic property coverage.”  The FAIR Plan website states: “While we will support homeowners regardless of a property’s fire risk, unlike traditional insurers, our goal is attrition. For most homeowners, the FAIR Plan is a temporary safety net – here to support them until coverage offered by a traditional carrier becomes available.”  While attrition may be the goal, the reality for many California homeowners is that coverage from a traditional insurer has not become available, and likely will not, as fires continue to rage throughout the state year after year.  Insurers continue to notify homeowners who live in threatened areas that they will not be renewing their coverage.  With the marketplace having so few affordable options, many have no choice but to turn to the FAIR Plan.

Because the FAIR Plan was intended to provide only “basic property coverage” and not other types of coverage such as personal liability or theft, homeowners would have to buy a secondary insurance plan in order to have comprehensive coverage equivalent to a typical homeowners insurance policy.  In 2019, recognizing the economic disadvantage to Californians living in fire-threatened areas, the Insurance Commissioner ordered the FAIR Plan to begin covering more than just basic property coverage.  The order required, in part, that by June 1, 2020, FAIR Plan must offer for sale to California consumers a comprehensive homeowners property insurance policy.  The FAIR Plan sued, arguing the Insurance Commissioner’s order was illegal in that the Commissioner lacked statutory authority under the Basic Property Insurance Inspection and Placement Plan to require FAIR Plan to sell a comprehensive homeowners policy.  This month, the court held that that the Commissioner did have statutory authority to require FAIR Plan to offer insurance which includes liability coverage, but only if that coverage is related to the property. The full text of the order can be found HERE:

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