Articles Tagged with insurance coverage

Kantor & Kantor, LLP recently achieved a victory in Olis-v.-Unum-Life-Insurance-Company-of-America No. 8:19-cv-01347-JVS-DFM, __ WL __ (C.D. Cal. July 27, 2020), a lawsuit seeking payment of an ERISA-governed disability claim based on debilitating migraines. Disability cases involving subjective reports of pain may be the most difficult benefit cases courts have to consider. This case provides a good example of what makes for a convincing claim, and what courts are looking for in deciding whether to award benefits. Our client was represented by Kantor & Kantor attorneys, Brent Dorian Brehm, Sarah Demers, and myself, Peter Sessions.

The plaintiff in this case was a 36-year-old woman who was employed by Enterprise, the rental car company, as an account specialist, which involved significant computer use. She had suffered from headaches for much of her life, but in 2016 those headaches intensified into recurrent migraines, which were accompanied by vertigo and visual disturbances. She took a medical leave of absence to address her problems and then tried to return to work, but she only lasted another month before she had to stop working entirely. During this time, Plaintiff visited numerous doctors in a number of specialties, tried several medications, and attended countless physical therapy sessions.

Plaintiff submitted a claim for LTD benefits to Unum Life Insurance Company of America, which Unum denied on the ground that she had not presented sufficient evidence to prove that she could not return to work. Plaintiff unsuccessfully appealed, and then filed suit against Unum under ERISA. The parties filed cross-motions for judgment under Fed.R.Civ.P. 52.

The short answer: Yes, depending on how much time has passed since you first submitted your claim.

Consider the following scenario. You work for a company that has an insured long-term disability (“LTD”) plan that is governed by the Employee Retirement Income Security Act of 1974 (“ERISA”). Let us say the insurance company is Prudential Insurance Company of America. You go out on disability due to chronic pain and file a claim with Prudential on July 25, 2019. On August 19, 2019, Prudential acknowledges that it received your medical records, activities of daily living questionnaire, and work capacity questionnaire. But inexplicitly, it says it needs more time to decide your claim and takes a 30-day extension. In the meantime, Prudential reaches out to your doctor to request feedback on its medical evaluation conducted by one of its nurse reviewers. Prudential also seeks clarification from you regarding your medical history. On November 13, 2019, Prudential confirms that the file is complete, but it states it needs more time to decide your claim. It does not explain why it needs more time. Finally, on November 27, 2019, Prudential decides against you. Can you file a lawsuit?

According to Judge Jeffrey White in the Northern District of California, the answer is yes. See Hasten v. Prudential Ins. Co. of Am., No. 19-CV-07943-JSW, 2020 WL 3786229 (N.D. Cal. July 6, 2020).

The coronavirus pandemic has altered daily life for everyone across the globe, and caused tens of millions of job losses in the United States. Because losing your job often means losing your health insurance, this can be a double whammy for affected individuals.

Congress recognized this problem in 1985 by passing the Consolidated Omnibus Budget Reconciliation Act (COBRA), a law that protects employees by letting them continue the group health insurance coverage they enjoyed while employed for up to 18 months (and sometimes longer) after their termination. (As with any law, there are exceptions. Not every employer is governed by COBRA’s rules – for example, COBRA only applies to employers who have 20 or more employees.)

However, many people don’t know that they can continue their health insurance coverage, and often employers inadequately inform their employees of their rights under COBRA, or simply don’t inform them at all. This is illegal. COBRA requires employers to provide written notice to terminated employees of their coverage options.

When a homeowner obtains insurance, she generally assumes the insurance company will accurately estimate the cost of rebuilding the home in the event of a disaster such a fire. Unfortunately, this is not often the case. Insurance companies rely on computer programs to generate an estimated cost to rebuild in an area. Some insurance companies will calculate the amount based solely on the square footage and age of the home. If an appraiser is not sent out when insurance is requested to inspect the home, upgrades such as vaulted ceilings, wood beams, updated kitchens and baths, hardwood floors, outdoor kitchens, finished basements or attics, or other enhancements will not be included in the amount allotted to rebuild your home.

Courts often decline to reform the insurance policy to fix errors in the estimated replacement cost, noting that the homeowner should have reviewed and contested the amount when she received the policy. Insurance policies often have extended policy limits that will add an additional 25% on the insured amount for just these situations. However, an additional 25% may not be enough to rebuild.

The West Coast is an especially high cost of living area, and that includes construction costs. The San Francisco Bay Area, for example, is currently the most expensive area of the country for new construction, with construction costing an average of $417/sq ft. Construction costs in California have been rising 5-6.3% per year. This is especially true in areas at high risk of wildfires. While many of those areas are more rural and populated with homes that are less expensive than those in major cities, the repeated years of fires and construction have affected the cost of construction in those areas.  It routinely costs $300-$350/sq ft to rebuild in rural wildfire areas.  Years of fires have created a huge demand for construction labor, and chronic shortages of materials.  County offices are also overwhelmed with permit requests. Delays have increased to the point that the California Department of Insurance has mandated that for wildfire disasters, the time provided by insurance companies to rebuild and to pay Additional Living Expenses be extended from 24 to 36 months.

The riots throughout the United States have been heartbreaking on a number of levels. While the social and political implications will be something our country grapples with for years into the future, the economic effects will be felt immediately.

Small businesses, already devastated by the pandemic and government-mandated shutdowns, are now having to deal with damage from riots and looting.  How are businesses going to recover from this double assault on their bottom line?

Ideally, most businesses have insurance to provide security in the event of riots or looting.  However, many insurance policies have exclusions of or limits on activities that could be viewed as “terrorism.”  We do not yet know how insurers will categorize the riots.

Kantor & Kantor has established a regular, live, and interactive Zoom conversation to discuss generally and answer questions from the public about long-term disability, health insurance, pensions, life insurance, casualty (homeowners), and more.  BenefitsChat will be live on Wednesday evenings from 5:00 pm – 6:30 pm Pacific Time.

Host Andrew Kantor, his fellow Kantor & Kantor attorneys, and select guests will explain and discuss everything from “big picture” concepts, such as the distinctions between different ways of obtaining insurance, to case-specific concepts designed to help individuals protect their rights.

While there is always a demand for legal information, current events have created an unparalleled need for as many real, live, helping hands as are available to be lent—even if the hand can only be safely lent via webcam. This forum will give people the chance not only to learn from our attorneys and each other; but to do so within the safety and comfort of a like-minded and supportive group of individuals and their families.

Two decisions this week emphasize the importance of submitting treating physician and patient statements in support of an ERISA administrative appeal. For ERISA health cases involving medical necessity denials, an appeal which gets to the heart of why treatment was medically necessary is crucial and can actually determine the course of the lawsuit.

In Katherine P. v. Humana Health Plan, Inc., No. 19-50276, __F.3d__, 2020 WL 2479687 (5th Cir. May 14, 2020), the Fifth Circuit revived life into a claim by a young woman seeking mental health benefits for partial hospitalization treatment. Katherine received partial hospitalization treatment in 2012 for multiple mental health disorders including an eating disorder. Humana paid for the first 12 days of partial hospitalization treatment and then denied benefits, claiming such treatment was no longer medically necessary based on two Mihalik Criteria.

The Fifth Circuit found that judgment for Humana was improper because the administrative record showed a genuine dispute as to whether Katherine satisfied one of the Mihalik Criteria, ED.PM.4.2.

On April 14, 2020, California Insurance Commissioner Ricardo Lara and the California Department of Insurance (“CDI”) directed all agents, brokers, insurance companies, and other Department licensees to accept, forward, acknowledge, and fairly investigate all business interruption claims caused by the COVID-19 pandemic.

The agency said that, “despite the Department’s on-going guidance to businesses statewide during the COVID-19 pandemic, it has received numerous complaints from businesses, public officials, and other stakeholders asserting that certain insurers, agents, brokers, and insurance company representatives are attempting to dissuade policyholders from filing a notice of claim under its Business Interruption insurance coverage, or refusing to open and investigate these claims upon receipt of a notice of claim.”

The Regulations require all agents, brokers, insurance company representatives, and other Department licensees to accept any communication from the policyholder or its representative indicating that the policyholder desires to make a claim against a policy that reasonably suggests that a response is expected as a notice of claim. Upon receipt of a notice of claim, every Department licensee is required to transmit such notice of claim to the insurer immediately.

For Immediate Release

May 7, 2020

Kantor & Kantor, LLP and Dawson & Rosenthal, P.C. FILED A COMPLAINT in the United States District Court, Central District of California on behalf of their client Sovereign Health, a Gold Star Award winning healthcare provider that treated mental health, substance abuse, and dual diagnosis patients . The $1.125 billon suit alleges that Health Net, Centene Corporation, attorneys from Manatt, Phelps & Phillips, and others engaged in practices that are in violation of the Racketeer Influenced and Corrupt Organizations Act (RICO); Conspiracy to Violate RICO; Intentional Interference with Prospective Economic Advantage, Violation of Unfair Competition Law; and Slander.

Fire season is beginning again in California, and soon throughout the West. Thousands of people are still trying to recover and rebuild from the years of past fires and related devastation. It is often taking three or more years to rebuild a home because of difficulties obtaining permits, contractors, and materials.

Ideally, your insurance company will work with you in this difficult time in your life. You will need to obtain a copy of your insurance policy and review it carefully. This can be harder than it seems if you have just lost all your possessions in a fire, as you may not even have access to a computer for some time. It is important to understand that the amount the insurance company set to insure your house may be much less than it would cost to rebuild your house. The insurance company will also only pay to rebuild your house as it was before, it will not pay for upgrades.

You will be asked to provide lists of the contents of your home. Then the insurance company will likely only reimburse you for the “actual cash value” of the possessions you lost in the destruction of your home, which removes depreciation from the value of your items. If your policy covers it, once you actually replace the item, you may receive a second payment covering that depreciation. But if you do not replace the item, you never will.

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