Insurance denial

June 16, 2020

June is National PTSD Awareness Month

National Post Traumatic Stress Disorder (“PTSD”) Awareness Month is commemorated annually in June. The month is dedicated to raising awareness of PTSD and how to access treatment. June 27 is also recognized annually as PTSD Awareness Day.

According to the National Center for PTSD, between 7 and 8 percent of the population will experience Post Traumatic Stress Disorder (PTSD) during their lifetime. Men, women, and children can experience PTSD as a result of trauma in their lives. Events due to combat, accidents, disasters, and abuse are just a few of the causes of PSTD. No matter the reason, PTSD is treatable, but not everyone seeks treatment, or some people seek treatment and they are denied benefits by their health insurer.

Common symptoms of PTSD might include:

June 4, 2020

Business Insurance and Damage from Riots

by Stacy Monahan Tucker

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.

May 29, 2020

Kantor & Kantor, LLP to Establish BenefitsChat, a Live Forum so the Public Can Ask Attorneys About Insurance Benefits

by Kantor & Kantor LLP

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.

May 19, 2020

How Your ERISA Appeal Can Change the Course of Your Future Lawsuit

by Elizabeth K. Green

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.

May 8, 2020

Filing an Insurance Claim for a Home Destroyed or Damaged by Fire

by Stacy Monahan Tucker

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.

April 14, 2020

Receipt of Short-Term Disability Benefits May be a Condition for Long-Term Disability Benefits

by Zoya Yarnykh

An employee who becomes disabled while covered by an employer-sponsored disability plan may qualify for short-term disability (STD) benefits and then long-term disability (LTD) benefits, based on the length of the disability and the terms of the plan. However, some LTD policies require that the employee not only apply for STD, but “exhaust” it, meaning receive the maximum amount of benefits allowed under the policy, before they may pursue LTD. If an employee received all but one day of the full STD benefit, they may still have to go through the appeals process or risk eligibility for the more valuable LTD benefit.

Kantor & Kantor was recently retained by a client, who we will refer to as John Smith for anonymity. Mr. Smith was employed by a large corporation as a Material Handler who was responsible for all supplies and materials needed to manufacture medical devices. Unfortunately, he became disabled by degenerative disc disease and painful spondylosis of his lumbar spine. In addition, he suffered from sciatic nerve pain in his back. His painful conditions necessitated medications which also caused side effects and impacted his functioning.

Mr. Smith’s company’s disability plan claim involved the situation described above, except that his STD claim was terminated just a few weeks before he received the maximum duration of benefits. He unsuccessfully appealed his STD denial on his own before hiring the law firm. In evaluating his STD claim and his potential LTD claim, the attorneys identified the following language in his LTD policy:

April 1, 2020

California Insurance Companies Directed to Provide Increased Telehealth Services During the COVID -19 State of Emergency

by Cari M. Schwartz

On March 30, 2020, California Insurance Commissioner Ricardo Lara and the California Department of Insurance (“CDI”) directed health insurance companies to increase access to services delivered via telehealth during the COVID-19 state of emergency.

The agency said that increasing the availability of telehealth will “lessen the strain on the supply chain, reduce the need to use scarce stocks of provider personal protective equipment and protect the ability of the healthcare workforce to provide care by limiting physical exposure to potential sources of infectious disease,” the notice states.

To support expanded telehealth, CDI said insurers should allow all network providers to use all available modes of virtual care delivery, including video and telephone-based communication. Insurers are also required to reimburse telehealth services costs at the same rate as in-person office visits, effective March 30, 2020.

March 24, 2020

COVID-19 and Business Interruption Coverage

by Stacy Monahan Tucker

You have a business, and you were a responsible business owner. You insured it against a variety of possible calamities, and included business income interruption insurance so you could continue meeting your financial obligations even if there is a disaster.

But then COVID-19 hit, and the government put everyone in your area on lockdown. Maybe your business can’t operate at all remotely, or maybe it “just” has taken a huge hit as people stay home. Regardless, now is the time you need your insurance.

You May Hear Disturbing News

January 31, 2020

What ERISA Rights Do I Have After I Appeal My Denied Long-term Disability Claim?

by Michelle L. Roberts

Over the past 15 years, I have represented hundreds of claimants in their claims for disability benefits governed by the Employee Retirement Income Security Act of 1974, also known as ERISA. If an ERISA disability claim is denied, a claimant must appeal that denial to the plan administrator or insurance company before he or she is able to file a lawsuit. The appeals process is referred to as exhausting administrative remedies (though there is no administrative agency involved). The ERISA Regulations provide rules that an administrator must follow in order to give a claimant a “full and fair review.” See ERISA § 503; 29 CFR § 2560.503-1 (Claims procedure).

Effective April 1, 2018, the ERISA Regulations were changed to require that an insurance company or administrator provide to the claimant copies of new evidence it obtains after a claimant submits an appeal so that the claimant has an opportunity to respond to the new evidence before the insurance company issues a final claim decision. Some insurance companies, however, refuse to provide this evidence to claimants who filed their disability claims before April 1, 2018.

What if you fall into this pre-April 1, 2018 category? Do you have any rights to know what the insurance company is relying on before it issues a final decision on your appeal?

January 22, 2020

Five Attorneys from Kantor & Kantor, LLP Have Been Selected to the 2020 Southern California Super Lawyers List

by Kantor & Kantor LLP

Kantor & Kantor, LLP, one of the most experienced law firms in the nation dealing with litigating insurance claims against insurance companies, is proud that once again five Partners have been selected to the 2020 Southern California Super Lawyers list. Co-Founders Lisa Kantor and Glenn Kantor are joined by Senior Partners Alan Kassan and Corinne Chandler, and Partner Brent Dorian Brehm makes his fourth consecutive appearance.

No more than five percent of the lawyers in Southern California are selected by Super Lawyers. Super Lawyers, part of Thomson Reuters, is a rating service of outstanding lawyers from more than 70 practice areas who have attained a high degree of peer recognition and professional achievement. The annual selections are made using a patented multiphase process that includes a statewide survey of lawyers, an independent research evaluation of candidates and peer reviews by practice area. The result is a credible, comprehensive and diverse listing of exceptional attorneys.

The Super Lawyers lists are published nationwide in Super Lawyers Magazines and in leading city and regional magazines and newspapers across the country. Super Lawyers Magazines also feature editorial profiles of attorneys who embody excellence in their practice of law. For more information about Super Lawyers, go to SuperLawyers.com.