Articles Tagged with insurance

Autoimmune disease is a broad category of related diseases in which a person’s immune system mistakenly attacks the tissues and organs it was designed to protect. Normally, the body’s immune system protects it by responding to invading microorganisms, such as bacteria and viruses. The immune system produces antibodies, which are special proteins that recognize and destroy the invaders. Autoimmune diseases occur when these autoantibodies attack the body’s own cells, tissues, and organs.

Autoimmune Facts:

  • There are more than 100 autoimmune diseases.

One of the most crucial pieces of evidence in supporting a long term disability (LTD) 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, the doctor is unable or unwilling to assist. There are a variety of reasons for this: lack of time, lack of compensation, misunderstanding of the level of involvement required by the doctor, employer/hospital rules preventing them, and in some cases, a disbelief that their patient is actually disabled.

If you have a disabling condition and you are making an LTD claim, or you are receiving benefits, your doctor’s participation in the process is essential. Without a doctor’s support, in most cases, your claim is finished. If your doctor has notified you that he or she will not be able to assist you with your claim, it is important to ask him or her to tell you the reason for their decision. If it is anything other than lack of belief that you are disabled, often, further information can change their minds. The offer of additional compensation for their time is a big help. Explaining that they will not have to do anything more than the forms or a letter – that they will not have to testify in court – goes a long way in changing minds.

If you have a disability insurance policy, you probably assume that if you’re unable to perform the duties of your job because of your medical condition, you’re entitled to benefits under your policy.

Not so fast! You may be surprised to learn that most disability policies don’t insure you from being unable to perform the duties of your job – instead, they insure you from being unable to perform the duties of your occupation.

What’s the difference? Well, as insurers will tell you, they are concerned about insuring people when they don’t know what those people are doing. There are too many jobs with individual specific duties performed in a variety of idiosyncratic ways for insurers to keep track of. As a result, they only insure the “type” of job you have, i.e., the job as it is typically performed in the national economy.

Almost one year since the beginning of the COVID-19 pandemic and it is clear that the effects of COVID-19 go beyond the numbers of cases and deaths.

How many people are struggling under the stresses of the pandemic? Is mental health suffering as Americans try to manage isolation, worries about jobs, and a constant stream of anxiety-producing headlines? Are they putting their future health at risk by delaying trips to the doctor or avoiding the emergency room when needed?

The Household Pulse Survey is an experimental survey designed to help answer these questions by capturing data in new ways. This survey is a cooperative effort between the Centers for Disease Control and Prevention, the U.S. Census Bureau, and several other government agencies to provide critical, up-to date information about the impact of the COVID-19 pandemic on the U.S. population. The Household Pulse Survey is different from other surveys conducted by the Census Bureau since it was designed to be a short-turnaround instrument that provides valuable data to aid in the pandemic recovery.

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.

Did your insurance company cancel your insurance due to nonpayment of premium during COVID? Be aware that most states have either requested, or required, insurers to institute a moratorium on cancellations due to nonpayment during at least part of the pandemic.  If your insurance company cancelled your insurance during COVID, remind them of this fact and ask them to reinstate your policy.  If they refuse, you may want to talk to a lawyer.

The entire West Coast has seen their Departments of Insurance issue requirements on this subject:

California:  On March 18, 2020, California issued a “request” to all insurance companies on March 18, 2020 to provide insureds “at least” a 60 day grace period to pay insurance premiums, and to ensure that policies are not cancelled for nonpayment of premiums due to coronavirus. http://www.insurance.ca.gov/0400-news/0100-press-releases/2020/release030-2020.cfm

On Monday, the White House issued President Trump’s Executive Order on Saving Lives Through Increased Support For Mental-and Behavioral-Health Needs, which orders the creation of a Coronavirus Mental Health Working Group (“the Working Group”), the submission of a plan by the working group for addressing mental health impacts of COVID-19, and calls for agencies to maximize support, including safe in-person services, for Americans in need of behavioral health treatment. The Working Group will issue recommendations in 45 days.

Health and Human Services Secretary Alex Azar, who will serve as co-chair for the Working Group, issued the following statement,

“We know that the COVID-19 pandemic has created or exacerbated serious behavioral health challenges for many Americans, both adding new stresses and disrupting access to treatment. The President’s Executive Order is a welcome opportunity to increase efforts to address the mental health effects of the pandemic, which have already included hundreds of millions of dollars in grants and historic flexibilities to ensure Americans can continue to receive treatment for mental illness and substance use disorders.”

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.

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:

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