Here are the resources that were mentioned during our July 22, 2020 BenefitsChat.
The presentation can be accessed here:
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).
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:
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.
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.
The Lupus Foundation of America estimates that 1.5 million Americans, and at least five million people worldwide, have a form of lupus. According to the Lupus Foundation of America most lupus sufferers are misdiagnosed or can go undiagnosed for years. The goal of Lupus Awareness Month is to inform practitioners, patients, care givers, and the general public about how best to diagnose, care for, and live with lupus.
What is Lupus?
Lupus is a chronic (long-term) disease that can cause inflammation and pain in any part of your body. Lupus is a non-contagious autoimmune disease, which means that your immune system — the body system that usually fights infections — attacks healthy tissue instead. According to the Centers for Disease Control and Prevention about 9 out of 10 diagnoses of lupus are in women ages 15 to 44 and most people with lupus develop the disease between the ages of 15-44.
Even though most of us are still sheltering in place in an attempt to lessen the immediate spread and most severe health consequences of COVID-19, it is not too soon to start considering possible long-term health impacts that may arise in the wake of the coronavirus pandemic.
Because the virus affects many organs and systems within the body – from the lungs and cardiovascular system to the liver, kidneys and likely the brain – it now appears likely that at least some patients will suffer long-term physical symptoms. These long-term and even permanent problems may result from the virus itself, the body’s own immune response or even medical interventions, especially respirators, or a combination of all these factors. But whatever the cause, doctors are already seeing heart damage, kidney and liver damage and, unsurprisingly, lung scarring and damage in a number of COVID-19 patients who are no longer actively infected.
And these are still early days. Some patients present during the illness with serious neurologic problems such as strokes and encephalitis, as well as other more mild neurologic symptoms such as dizziness, headache and loss of smell. There have been reports of some patients suffering from Guillain-Barré Syndrome, an auto-immune disease where the immune system responds to an infection by mistakenly attacking the body’s own nerve cells. It seems possible that at least some of these patients may continue to suffer neurologic and autoimmune issues, and related pain, fatigue and cognitive difficulties for at least some time.