Category: Health Insurance

Coronavirus Insurance Issues

The COVID-19 pandemic is causing many types of insurance questions. Below is an FAQ on some insurance issues people may be dealing with during the pandemic. As always, it’s important to keep in mind that the specific facts and insurance policy language will vary from case to case. An FAQ can’t take the place of legal advice from consulting with an attorney directly. But hopefully this will help point you in the right direction.

Health Insurance

Typical health insurance covers COVID-19 treatment just the same as any other illness. Washington’s Affordable Care Act (a/k/a Obamacare) exchange platform is allowing a special open enrollment period for qualified uninsured individuals to buy insurance on the state Exchange through April 8, 2020. This is an exception to the normal rule that you can only buy Exchange coverage during special periods.

There are also special rules for COVID-19 testing. The federal government designated COVID-19 testing as an essential health benefit, meaning that Medicaid and Medicare plans should cover testing. Washington’s Office of the Insurance Commissioner has ordered health insurers to cover COVID-19 testing without deductibles or cost-sharing. Also, insurers have to allow patients to refill necessary prescriptions regardless of the normal waiting periods.

Disability Insurance

Employees unable to work due to COVID-19 might have recourse under disability insurance policies.  Disability coverage should provide benefits for folks who can’t work because they are sick. But, as always, the fine print matters. Many policies have waiting periods or other detailed rules for paying benefits. The specific rules will also depend on how you obtained coverage. Most folks get disability insurance from their employer, and will have to navigate the special claims procedures under ERISA. For folks who bought their policies themselves, claims will be governed by Washington State law which is generally more policyholder-friendly.

Business Loss Insurance

Businesses who close or lose revenue because of the pandemic or the state-ordered lockdown might have claims for business interruption coverage. This coverage is often provided by standard commercial insurance policies. These claims depend heavily on the specific policy language and facts. For example, some policies require actual physical damage to property before paying business interruption benefits. Other policies might require the business be closed by the authorities. It is also important to be able to document the specific losses incurred under business interruption coverage.

Know Your Rights

Anyone who thinks they have insurance coverage related to COVID-19 should be on top of their rights. In disasters like this pandemic, insurers often cut corners or underpay claims. Washington State insurance policyholders have important rights, including the right to a full, fair, and prompt investigation of their claim at the insurer’s expense. Insurers also have a duty to fully disclose all the potential coverage that you might have.

Finally, here are some resources for non-insurance issues relating to the pandemic:

 

 

 

 

Policyholders Can Sue for Health Insurer’s Refusal to Cover Proton Beam Therapy Cancer Treatment Says Washington Supreme Court

On October 3, 2019, the Washington Supreme Court decided Strauss v. Premera Blue Cross, holding the Strausses could sue Premera Blue Cross for denying coverage for Proton Beam Therapy to treat prostate cancer.

Mr. Strauss had a Premera health insurance policy. The policy promised Premera would pay for “medically necessary” treatment. Mr. Strauss was diagnosed with prostate cancer and his doctor recommended Proton Beam Therapy treatment. Mr. Strauss’ doctor believed Proton Beam Therapy had fewer side effects than traditional radiation therapy because it exposes less of the body to radiation.

Premara refused coverage, claiming Proton Beam Therapy was not “medically necessary.” Premara said there was no proof Proton Beam Therapy had fewer adverse side effects than traditional radiation therapy. The Strausses filed a lawsuit.

Because there were no clinical studies on point, the Strausses supported their case with testimony from two radiation oncologists that Proton Beam Therapy would lead to fewer side effects because it exposed less of the body to radiation. Premera argued the Strausses could never prove Proton Beam Therapy was medically necessary without clinical studies. The trial court agreed with Premera and dismissed the lawsuit.

The Washington Supreme Court reversed, holding the Strausses’ case could move forward. The Supreme Court emphasized the absence of clinical evidence did not bar the Strausses’ claim. The Supreme Court found the Strausses’ expert doctors were qualified and that the trial court was wrong to reject the doctors’ opinions purely because no clinical studies existed. Importantly, the Supreme Court also rejected certain prior cases Premera relied on, holding those cases were wrongly decided.

The Strauss case is an important victory for policyholders and patients. Health insurance disputes can be very difficult, particularly because health insurance policyholders often have fewer consumer protections and are at greater risk of abuse by their insurers. Health insurers often use the words “medically necessary” as magic words that mean you have no right to the healthcare your doctor prescribed. This is especially true with novel treatments for complex diseases like cancer. This ruling will hopefully empower more people to pursue the treatment they need without worrying about insurance coverage.

Washing State’s “homegrown” health insurers credited with keeping rate increases low

Preliminary reports suggest Washington State’s Affordable Care Act (a/k/a Obamacare) plans will see minimal rate increases in 2020. Washington State exchange plans are projected to see a 1% average rate increase, lower than almost half of other states in the U.S.

Washington’s Insurance Commissioner reportedly credited Washington-based health plans with the low increases. Washington-based insurers are tied to the local community. These insurers rely on keeping local business in order to thrive. Local plans also tend to have better relationships with doctors and hospitals. Large, national carriers, on the other hand, can lose Washington customers to cheaper plans.

This is good news for the approximately 250,000 Washington residents who buy insurance through Washington’s ACA/Obamacare exchange.

Health Plans Can’t Discriminate Against Mental Health Treatment Says Ninth Circuit

Among the challenges of a mental health condition is the difficulty persuading health insurers to cover treatment.  Mental health conditions can be difficult to objectively diagnose and can require lengthy and expensive treatment often with little prospect of a conventional “cure.”  Hence, health plans have a powerful incentive to minimize coverage for mental health conditions to reduce costs.

In response, the federal government, as well as Washington and many other states, have enacted mental health parity laws.  In general, these laws prohibit health insurers and health plans from discriminating against mental health conditions by mandating mental health conditions be covered to the same degree as physical ailments.

On June 6, 2018, the Ninth Circuit Court of Appeals confirmed the federal Mental Health Parity Act prohibits health plans from discriminating against mental health conditions for the purposes of health insurance coverage. In Danny P. v. Catholic Health Initiatives, the court determined the health plan violated the law by denying the plaintiff’s claim for the cost of an inpatient stay at a residential mental health treatment facility.

In ruling for the plaintiffs, the court determined the Mental Health Parity Act required the health plan’s coverage of inpatient mental health treatment facilities be no more restrictive than coverage for stays at skilled nursing facilities.  Since the Act prohibited imposing more restrictive coverage requirements on mental health treatment than on treatment for physical conditions, the Act precluded the health plan from deciding to cover room and board at skilled nursing facilities for medical patients while refusing to provide the same coverage for mental health inpatient care.

The Danny P. decision is an important win for patients seeking mental health treatment and vindicates Congress’ intent in passing the Mental Health Parity Act that mental health patients be free from discrimination by their health plans.