by Guest » Tue Aug 24, 2010 07:33 am
I'm a student of medicine from CO. I'm aware of dental insurance, but I recently attended a seminar where they stressed upon the necessity of a disability insurance policy. Do all dental surgeons need disability insurance?
Posted: Mon Aug 30, 2010 02:02 pm Post Subject:
Max, employer sponsored plans can be advantageous. Many of these are sex distinct and have discounts. This can be a huge money saver, especially for females. What the good ones have in common, though, is that they are individual coverage and not group coverage.
One huge disadvantage with group coverages is that they are covered under ERISA. This makes it much easier for insurance companies to deny claims with greater impunity.
Posted: Mon Aug 30, 2010 03:48 pm Post Subject:
Max, employer sponsored plans can be advantageous.
I'm sorry. Did you see anything in my posts to the contrary?
Many supplemental benefit plans are made available to employees by payroll deduction, but are not employer-sponsored plans. They are often low cost, and sometimes provide only limited benefits. The company with the quacking duck in its commercials should come to mind. Limited benefits does not mean lousy coverage, it simply means you have to know what is and is not covered. Some "disability income benefits" are only paid if, and only for as long as, a person is hospitalized. And even then, perhaps only if due to an accident.
One huge disadvantage with group coverages is that they are covered under ERISA. This makes it much easier for insurance companies to deny claims with greater impunity.
How can you make this statement? ERISA does not govern the provision of benefits themselves, state laws do, although ERISA does mandate that certain things be INCLUDED, such as maternity benefits, that are less likely to be found in an individual health insurance plan these days. ERISA preempts state laws that are in conflict with it, such as allowing an insured the right to sue an HMO in certain circumstances, or a law that allows maternity benefits to be excluded. But nowhere in ERISA does it state that insurance companies may deny claims in group insurance contracts with impugnity. The contract is the contract.
For example, ERISA has not been held to disallow states from setting up independent medical review boards in cases where an HMO patient's physician recommended a procedure, the HMO's internal review physician also recommended the same procedure, and the HMO still denied the procedure anyway. When the HMO denied it again after the state's independent review board recommended the procedure for the patient, and the patient paid for the $100,000 life-saving procedure on her own, she then sued the HMO, which claimed immunity under ERISA. The case went all the way to the US Supreme Court, and the insurance company was properly spanked by the high court. You can look up the case on the SCOTUS website. The decision involved an insurance company in the state of Illinois about 6-7 years ago. It cost the insurance company a far larger amount of money to deny that $100,000 surgical procedure.
ERISA intends to prevent discrimination in providing benefits to plan participants and plan beneficiaries within the same occupational class. It also describes "vesting schedules" and other eligibility requirements for group benefit plans offered/sponsored by employers with 20 or more full-time (or full-time equivalent) employees.
ERISA says nothing about an insurance company's right to deny claims when coverage is stated in a contract, and no insurance company has the right to deny claims with impugnity.
Just ask Unum, the company I mentioned above. They have first-hand knowledge of what can happen when an insurance company violates the language of the group and individual disability income contracts it issues. They paid millions of dollars in regulatory/administrative fines to almost every state in the US as the result of their misinterpretation of their own contracts' language, which led to claims denials and unfair claim practices charges.
There is no peculiar advantage or disadvantage to any group insurance policy under ERISA. And group insurance policies do not normally have less beneficial contract terms than individual policies. But some individual policies can be written with more favorable terms, and significantly higher premiums than group policies, simply because the employer is not willing to pay for the sun, moon, and stars.
And while ERISA provides for continuation of group health insurance (courtesy of COBRA 1985), it says nothing about continuation of group life or disability insurance. It does promise convertibility of group coverage to an individual plan of insurance without proof of insurability within 31 days of termination of eligibility for the group insurance.
If you have something specific to refer to, please do. Otherwise, don't make broad assertions that are untrue.
Posted: Mon Aug 30, 2010 07:35 pm Post Subject:
Max, Either you are unaware or spend too much time in the classroom. The issue with ERISA has nothing to do with benefits. It is an issue of claims. The claim’s process is spelled out and a claim will only be overturned if the denial is “arbitrary and capricious”. There are no consequential or punitive damages that the insured can collect. The best case scenario is that the claim will get paid and it is possible, but rare, for attorney fees to be rewarded.
Contrast this with non-Erisa policies. The burden of proof is identical to a civil trial. All that is needed is a preponderance of evidence and one can get punitive damages.
My opinion is that the Unum case would never have happened if the policies were not governed by ERISA. They would have had thousands of individuals successfully suing them and collecting damages. It’s not coincidental that most issues with difficulty in the clam’s process are with ERISA policies.
Max, let’s be serious here. If your disability claim was denied, would you rather it be an ERISA policy or a non-ERISA policy? The answer is cut and dry.
Posted: Tue Aug 31, 2010 10:20 am Post Subject:
The claim’s process is spelled out and a claim will only be overturned if the denial is “arbitrary and capricious”.
Can you show me through some examples?
Posted: Tue Aug 31, 2010 10:27 am Post Subject:
Nope. Just use your head. What do you believe is easier to prove?
1) With an Erisa policy, one must prove that their denial was "arbitrary and capricious".
2) With a non-Erisa policy, one can simply show a preponderance of evidence.
Posted: Wed Sep 01, 2010 01:29 am Post Subject:
It is an issue of claims. The claim’s process is spelled out and a claim will only be overturned if the denial is “arbitrary and capricious”. There are no consequential or punitive damages that the insured can collect. The best case scenario is that the claim will get paid and it is possible, but rare, for attorney fees to be rewarded.
Contrast this with non-Erisa policies. The burden of proof is identical to a civil trial. All that is needed is a preponderance of evidence and one can get punitive damages.
What are you taking about? Suing an insurance company or submitting a claim for disability.
The thread is not about suing an insurance company, it is about collecting disability benefits.
I will agree that ERISA protects insurers from civil actions in certain circumstances, but a claim is a claim. ERISA no more addresses the process of paying a claim than a private disability policy. You either fit the definition of disability in the contract or you don't.
What got Unum in trouble with its GROUP and INDIVIDUAL policies was a clear and deliberate misapplication/misinterpretation of its own occupation definition. Telling nurses, among others, that normally were on their feet all day caring for patients that sitting at a desk all day was their "own occupation" and that they did not qualify for a benefit. ERISA provided no protection for the insurance company against the multimillion dollar settlement with the states for unfair claims practices.
Your post about ERISA making it possible for insurance companies to deny claims without impugnity is WAY OFF BASE!
As Billnorris asks, can you offer some examples? I have. You simply state, "Nope, use your head."
If nothing else, please identify the specific sections of ERISA that you are basing your posts on. (Like Section 404(c) that requires employers to provide "education" to their employees concerning a defined contribution plan.) At this point, your posts are like the person who quotes one passage of the Bible out of context to seemingly prove his point. When you get the whole context, everything may be very different.
Specificity, please, specificity!
Posted: Wed Sep 01, 2010 03:43 am Post Subject:
Max, connect the dots. If you were a dishonest insurance executive looking to maximize profits which claim would you be more likely to decline?
a)an ERISA policy
b)a non-ERISA policy
We both know the answer. Denial of an ERISA claim will ultimately cost the insurer the amount of the claim. Denial of a non-ERISA claim can cost the insurer the amount of the claim + damages.
As things currently stand, it makes financial sense for insurance companies to be more strict with ERISA policies, thus making it harder to get paid on a legitimate claim.
Posted: Thu Sep 02, 2010 04:15 pm Post Subject:
If you were a dishonest insurance executive looking to maximize profits which claim would you be more likely to decline?
Well, if this was the reasoning behind Unum's "little problem", then it did not work.
ERISA or not, UNFAIR CLAIMS PRACTICES is still an enforceable offense, and is taken seriously.
Your cynical attitude about "insurance executives" is not supported by the evidence of claims payments. Insurance companies are in business to make money. We can agree on that. But insurance companies STAY IN BUSINESS by paying claims.
If an insurance company was so callous as to deny claims simply because they cannot be subject to a class action lawsuit would cause them to lose their Certificates of Authority in the states where they do business. No business . . . no profits.
Your reasoning is faulty, and claims under group disability policies are no more likely to be denied improperly than claims in individual policies. If you have EVIDENCE to the contrary, post that, not your "what if" conjectures.
Posted: Thu Sep 02, 2010 10:19 pm Post Subject:
Unfair claims practices are an enforceable offense. However, it is much harder to prove based upon an "arbitrary and capricious" standard.
It's not about callously denying claims that obviously should be paid. It's about denying claims that have some shades of gray. It's much harder collecting on ERISA policies. If you had more clients, you would see much more of this.
Here's an analogy: If you jaywalk on Smith Avenue and get caught, the police officer will make you cross the street at the crosswalk. If you jaywalk on Charles Avenue, the police office will make you cross at the crosswalk and fine you $250.
Result: more people jaywalk on Smith Avenue because of the lack of penalties. The same is true for ERISA policies.
The closest to evidence that I can give to you if using common sense won't work is to do some research yourself. You'll quickly find that most issues in terms of claims are with ERISA policies.
Posted: Tue Sep 14, 2010 12:46 am Post Subject:
Just snooping on another "advice" website, I came across the following bit of advice. Notice, there is no discussion of "arbitrary and capricious", but a thorough explanation that there are specific steps to pursuing a claim in an ERISA-governed policy, not that it is impossible. Mostly, everything hinges on an insured's ability to follow the process through the proper steps in the proper sequence.
And as you read the information on a claims denial and appeal, the insurance company has to specifically state the reason for the claims denial, which in my mind, reduces the likelihood of "arbitrary and capricious" action on the part of the insurer.
The following may be found at http://law.freeadvice.com/insurance_law/disability_insurance/appeal-erisa-claim.htm
Your right to sue on a denied-ERISA disability insurance claim is limited. (ERISA, an acronym for Employee Retirement Income Security Act of 1974, is the federal law that governs most employer-provided health plans.) In a nutshell, if your claim for disability has been denied and upheld on appeal, you can file a lawsuit. Failure, however, to pursue the internal administrative appeal process within the insurance company is often fatal to a lawsuit action.
To tackle an ERISA claim, there are two mandated steps to follow:
1. an initial filing of your claim with the insurance company and a determination by the claims reviewer;
2. if denied, you have two choices
1. accept that decision or
2. appeal for another internal review within the insurance company.
Both involve deadlines which are spelled out in your plan and in a denial letter. If you do nothing, you may lose appeal rights and your right to head for court.
Importance of Appeal Process: Assembling the Administrative Record
The purpose of the ERISA appeal process is two-fold. First, it gives you an opportunity to rebut the decision of the claims reviewer. Second, in most instances, it is the final opportunity for you to include favorable evidence in the administrative record for purposes of a subsequent lawsuit if your appeal is denied. (The “administrative record” is actually the insurer’s file on your case.)
How critical is the appeal process? If you end up in a lawsuit, it is the information existing in the insurance file (the “administrative record”) that will be considered by the court. In other words, what is in your record has a significant impact on your ability to recover. In most cases after the appeal process is done, you are not allowed to add evidence—no matter how pertinent to your claim—and have it heard later. Your administrative file may be your one chance to make your case. It is crucial to get the file right—to carefully assemble as full and credible administrative record as possible.
Information that must be provided to you at the time of the initial denial
If your claim is denied, the claims reviewer must do these things in the coverage denial letter:
1. advise you of the specific reason(s) for the denial;
2. reference the specific policy provision on which the determination is made;
3. describe what additional material or information, if any, is necessary to make the claim valid;
4. explain what steps need to be taken to have the claim denied reviewed;
5. advise you of your right to bring a subsequent law suit under ERISA; and
6. either provide or offer to provide any internal rules, guidelines or criteria that were relied upon in making the claims decision.
If this information is not provided to you at the time of initial denial of your claim, a court may rule that the denial is incomplete and your appeal period has not yet started.
Information that must be considered on appeal
It is extremely important to load the administrative review record with all information that substantiates your disability and your right to benefits. Think creatively on how to prove your case. This includes an accurate job description, an employer’s statement, medical literature in support of your claimed disability, detailed opinion letters from doctors, your employment history, disability experts, functional capacity evaluations or vocational appraisals, video testimony from your family, boss, and co-workers, progress reports, timelines, and so forth.
To maximize the chances of your success on your appeal, request from the insurer copies of all relevant documents including its own medical reviews performed on your records. Since the reasons for denial are laid out in the denial letter, rebut each reason raised with logical, persuasive arguments supported by credible evidence and expose any weakness in the insurance company’s position(s).
List all documents by name and date and number each page in all correspondence to the insurance company and its representatives to create a clear record of what you have provided.
Exhaustion of administrative remedies
This cannot be emphasized enough: If you snooze during the appeal period, you lose. You must pursue all of the appeal procedures offered by your insurance plan as stated in the denial letter before you sue. Your lawsuit will be dismissed if you have not exhausted all administrative remedies.
Full and fair review
The appeals committee or the appeal reviewer – different from the person who made the denial decision—is required to conduct a “full and fair review” of all comments, documents and records submitted by you related to your appeal. The reviewer must not give deference to the initial benefit determination.
Time limit on a decision
You will hear from the appeal reviewer, in writing, within 45 days of filing. There may be extensions under certain circumstances.
For a discussion of the damages on an ERISA lawsuit, click here.
Because the legal and procedural rules applied to ERISA denial claims are complex, it is strongly urged as soon as possible to call a private attorney experienced in insurance cases and bad faith litigation to help assemble a compelling administrative record. Insurance company lawyers are top notch group of attorneys who will be extremely competent and knowledgeable about ERISA disability claims and know the answers real well.
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