LA Times Report: Pervasive Problem of Improper Health Insurance Denials

Posted in: Disability Insurance News, Health Insurance, Legal Articles February 03, 2018

After using a diabetes insulin pump for nine years, David Lazarus suddenly received a denial letter from his insurer, Blue Cross Blue Shield of Illinois. The denial letter notified Lazarus that his employer’s health plan would no longer cover the cost of his diabetes insulin pump. He was now responsible for the cost of the pump: $8,703. The reason cited for his insurer’s sudden change of heart? Lack of medical necessity. His medical insurance claim was denied.

An insurer may deny a medical insurance claim before or after the medical service sought to be covered, either through the denial of preauthorization requests or denial of claims for payment after the medical service is provided. Some insurers require preauthorization requests before …

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Plan Administrators Cannot Violate their Fiduciary Duties by Failing to Provide Proper Notice of Policy Amendments; ERISA Plan Exclusions/Limits May Not be Enforceable

Posted in: Disability Insurance, Disability Insurance News, ERISA, Group Plans, Health Insurance, Insurance Litigation Blog, News Blog September 28, 2017

Summary Plan Descriptions (“SPD”) under ERISA are required to be given to plan participants, and they provide plan participants with the most important summary of plan terms they need to know regarding their ERISA governed plans.  ERISA requires SPDs to “be written in a manner calculated to be understood by the average plan participant.”  However, plans will sometime issue numerous plan modifications which can add up quickly and require plan participants to read a series of plan modifications in addition to the original SPD in order to determine their available benefits, rights, and obligations.  To further complicate matters, benefit determinations may often be made by two separate entities.  A Plan Administrator may make an initial appeal decision, and a Plan …

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Summary Plan Descriptions Under ERISA May Do More Than Summarize Your Benefit Plan

Posted in: Disability Insurance, Disability Insurance News, ERISA, Group Plans, Health Insurance August 05, 2017

When individuals are enrolled in a group benefit plans, they are typically provided with a “Summary Plan Description” (“SPD”) which is a document that communicates plan rights and obligations to participants and beneficiaries under their ERISA plan. While the actual Benefit Plan Trust Agreement, which contains the formal provisions that make up a benefit plan, is usually made available to participants, the separate SPD is traditionally provided in order to summarize the material provisions of a Benefit Plan documents in a way that can be understood by an average benefit plan participant, as the actual Benefit Plan document can be extremely lengthy and complex. However, sometimes the provisions in the SPD can differ from those in the Benefit Plan or …

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9th Circuit puts final nail in coffin for discretionary clauses in insurer-funded ERISA plans

Posted in: Abuse of Discretion, Case Updates, De Novo Review, Disability Insurance, Disability Insurance News, ERISA, Health Insurance, Insurance Litigation Blog, Life Insurance, Policy Interpretation, Preemption, Standard of Review May 24, 2017

Disability and life insurers frequently include clauses in their insurance policies affording them complete discretion to decide whether a claim has merit.  The clauses usually state the insurer has total discretion to decide whether the claimant is eligible for the policy’s benefits, to decide the amount, if any, of benefits to which they are entitled, to interpret the policy’s terms how they see fit, or something similar.  Employers regularly include these same types of “discretionary clauses” in their employee welfare benefit plan documents, and if a group insurance policy is the funding source of the plan’s benefits, they then delegate that discretion to decide the merits of claims to the insurer.

Employee benefit plans and the corresponding group insurance policies …

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When and Why Government Plans are not Governed by ERISA

Posted in: Bad Faith, Breach of Contract, Church Plans, Disability Insurance, ERISA, Health Insurance, Insurance Bad Faith, Insurance Litigation Blog, Insurance Questions and Concepts, Life Insurance, Long Term Care Insurance, Property & Casualty Insurance February 24, 2017

The McKennon Law Group PC periodically publishes articles on its California Insurance Litigation Blog that deal with related issues in a series of articles dealing with insurance bad faith, life insurance, long-term disability and short-term disability insurance, annuities, accidental death insurance, ERISA, and other areas of the law.  To speak with a highly skilled Los Angeles long-term disability insurance lawyer at the McKennon Law Group PC, call (949)387-9595 for a free consultation or visit our website at www.mckennonlawgroup.com and complete a free consultation form.

Determining what law governs your health, life, or disability insurance claim is the first step in the process of defending a wrongfully denied claim.  Generally speaking, if you have a denied life, disability or health insurance …

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How Insurers Deny Legitimate Health Insurance Claims

Posted in: Bad Faith, Disability Insurance News, ERISA, Health Insurance, Insurance Bad Faith, Insurance Litigation Blog February 21, 2017

The McKennon Law Group PC periodically publishes articles on its California Insurance Litigation Blog that deal with related issues in a series of articles dealing with insurance bad faith, life insurance, long-term disability and short-term disability insurance, annuities, accidental death insurance, ERISA, and other areas of the law.  This is the third in a series of articles on How Insurance Companies Deny Claims.  To speak with a highly skilled Los Angeles long-term disability insurance lawyer at the McKennon Law Group PC, call (949)387-9595 for a free consultation or visit our website at www.mckennonlawgroup.com and complete a free consultation form.

The U.S. Department of Labor estimates that about one claim in seven made under the employer health plans that it oversees …

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The Prevalence of Life, Health and Disability Benefit Claim Denials is Astounding: It’s Worse Than You Thought

Posted in: Abuse of Discretion, Bad Faith, Disability Insurance, Disability Insurance News, ERISA, Health Insurance, Insurance Bad Faith, Insurance Litigation Blog, Life Insurance February 02, 2017

The U.S. Department of Labor estimates that a whopping 75 percent of long-term disability claims are denied.  With over six decades of collective experience representing both insurers and their policyholders, the lawyers at McKennon Law Group PC have seen insurers routinely deny valid claims.  But that DOL statistic shocked even us!  Irrespective of the precise percentage, one thing is certain: life, health and disability insurers often deny valid benefit claims.  They deny claims at such an astounding level it leaves reasonable people wondering – is it an ingrained business practice aimed at maximizing insurer profits?

There is empirical support.  According to a recent column in the Los Angeles Times about denied health insurance claims:

Insurance companies are playing the odds …

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Have “Quack” Medical Reviewers Caused Denial of Your Long-Term Disability Claim? California Court of Appeal Berates Insurance Company for Controlling Medical Peer Reviews

Posted in: Bad Faith, Case Updates, Disability Insurance News, Expert Testimony, Health Insurance, Insurance Litigation Blog, Punitive Damages December 13, 2016

During their Presidential election campaigns, Donald Trump and Hillary Clinton spotlighted for America flaws in our criminal justice system.  They raised questions about whether the criminal probe into Ms. Clinton’s private email server was handled honestly or politically.  Conservatives bitterly complained that FBI director Jim Comey’s recommendation not to prosecute Ms. Clinton was inconsistent with the FBI’s fact findings (that she carelessly mishandled classified emails) and influenced by the left-leaning Justice Department rather than justice.  On the flip side, Liberals vehemently complained that on the eve of the election Director Comey made an unprecedented announcement that the FBI had reopened its criminal investigation into Ms. Clinton’s private emails, attempting to influence the election.…

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Health Insurance Law Update: Medical Providers Seeking Payment from Insurers Must File a Quantum Meruit Lawsuit Within Two Years of the First EOB

Posted in: Health Insurance, Insurance Litigation Blog December 06, 2016

The most common complaint McKennon Law Group PC hears from medical providers is that insurers refuse to pay for the services provided to their insureds, even after the medical provider sought and obtained a pre-authorization from the insurer for the services provided to a patient.  After submitting a bill to the insurance company, all too often, a physician or other medical professional receives an Explanation of Benefits (“EOB”) letter indicating that either the insurer will not pay the claim at all or it will only pay a fraction of the amount billed.…

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Department of Labor Proposes New, Claimant-Friendly ERISA Regulations for Disability Insurance Claims

Posted in: Disability Insurance News, ERISA, Health Insurance, News, News Blog December 10, 2015

From time to time, the U.S. Department of Labor promulgates new regulations governing disability insurance benefit claims and health insurance benefit claims that are governed by the Employee Retirement Income Security Act of 1974, commonly referred to as ERISA.  The regulations must be followed by plan administrators and claim administrators when reviewing disability insurance and health insurance benefit claims submitted by claimants.  Recently, the Department of Labor proposed changes to the regulations governing long-term disability insurance benefit claims and short-term disability insurance benefit claims.…

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