Articles Tagged with insurance coverage

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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Post-traumatic stress disorder (PTSD) is a mental health condition that is triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event.

According to the National Center for PTSD, a program of the U.S. Department of Veterans Affairs, about seven or eight of every 100 people will experience PTSD in their lifetime. Women are more likely than men to develop PTSD. Certain aspects of the traumatic event and some biological factors (such as genes) may make some people more likely to develop PTSD.

Even though PTSD treatments work, many people who have PTSD do not get the help they need. June is PTSD Awareness Month. The goal of PTSD Awareness Month is to spread the word that effective PTSD treatments are available.

When the disability insurance attorneys at Kantor & Kantor, LLP see what is happening with those whose COVID-19 symptoms are continuing for more than a month, they know that there is a good chance that long-term disability claims will be denied. Because of this, we have developed the COVID Longhaulers Legal Resource Center.

In fact, the symptoms that Longhaulers are experiencing match many of the same disabling symptoms those living with autoimmune diseases such as ME/CFS, Dysautonomia, POTS, and more.

Since the symptoms dovetail, we are confident that the inevitable problems and denials with the long-term disability insurance providers will follow suit.

Aaron Monheim, age 34, lives in Spokane, Washington with his wife and three year old daughter. In 2019, Aaron was diagnosed with aggressive relapsing remitting multiple sclerosis which has been unresponsive to medications and leaves Aaron partially disabled due to frequent flares and relapses.

Aaron’s physicians recommended him to receive a treatment called hematopoietic stem cell transplantation, found to be particularly suited for his form of relapsing remitting multiple sclerosis. The treatment will effectively reset his immune system so it will no longer attack his central nervous system. The treatment is also less costly than the traditional medications for multiple sclerosis which have been unsuccessful for Aaron.

Despite having been referred to the treatment by his own Kaiser doctor, Aaron’s health plan, Kaiser Permanente, has denied benefits for the treatment claiming the treatment is not necessary or suited for Aaron’s condition.

Dealing with insurance companies can often feel complex, challenging, and overwhelming. You are not alone. But it is always best to understand your mental health benefits BEFORE you need to use them. Mental health services may be covered in whole or in part by your health insurance or employee benefit plan. It is important to understand your mental health benefits as you will be responsible for any unpaid claims.

Here are some tips and questions to consider as you try to understand your mental health benefits.

  • Obtain a copy of your health insurance policy or employee benefit plan.

An alternative to health insurance marketplaces available through healthcare.gov are “short term” health insurance plans purchased through insurance brokers.

These short term plans have surprisingly low premiums and even slimmer coverage. The problems with these short term plans have caused four states – California, Massachusetts, New Jersey, and New York – to ban them.

Insurance brokers are incentivized with higher commissions to sell short term plans compared to Affordable Care Act (“ACA”) plans.  See more from Consumer Reports HERE

Most insurance companies unveiled national advertising campaigns in March 2020, promising to “pause” all policy cancellations or expirations for at least a month due to non-payment of premiums. Many continued this policy, stating that insureds simply had to ask to have their insurance payment plan extended during COVID-19.

Insurance companies did not do this out of the goodness of their hearts. In most states, the state insurance commissioner issued directives asking or requiring insurance companies to do exactly this. The federal government similarly issued regulations for policies governed by ERISA, extending the deadlines for appeals until after the pandemic ends.

Despite the state and federal mandates, and their own advertising, insurers have not all followed these requirements.  Many insurance companies did in fact still cancel or allow policies to lapse in the first month of the pandemic.  Many more put the onus on their insureds to reach out and request help, despite promises that all such extensions would be “automatic.”  Here is a summary of the positions taken by some of the major insurance companies:

First, a quick definition: A claim reserve is a reserve of money set aside by an insurance company in order to pay policyholders’ claims under their policies. Reserves are set by the insurance company in an amount that it anticipates having to pay out for the claim. Reserve information is important because it can show that the carrier undervalued the claim and never had the intent to pay the reasonable and necessary cost to repair the loss.

Despite being required by law to do so, homeowners’ insurers often improperly redact reserve information when producing claim file materials in litigation. Insurers also often to attempt to thwart an insured’s access to reserve information by objecting to deposition topics related to reserves. It is only when pressed that some carriers, whose counsel is aware of their untenable position, will concede and produce unredacted reserve information.

The Eastern District of California recently ruled on several discovery issues in a bad faith action involving a water loss. In Banga v. Ameriprise Auto Home Ins. Agency, No. 2:18-cv-01072-MCE-AC, 2021 WL 634955 (E.D. Cal. Feb. 18, 2021), a homeowner brought a bad faith action against her insurer after a dispute over insurance coverage for water damage to her home. As a result of high windstorm, the roof of the insured’s house was damaged, causing leakage that further damaged the interior walls and the vaulted ceiling of the house.

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