Category: Insurance

Court Ruling Emphasizes Tie Goes to the Policyholder When Interpreting Insurance Policies

Washington insurance law includes a principle that if an insurance policy is ambiguous, i.e., if it can reasonably be read in multiple ways, the court will adopt the reading that is most favorable to the policyholder.  This rule exists because insurance companies are sophisticated enough to draft their insurance policies the way they want, and have enough leverage over the consumer to offer their policies on a take it or leave it basis.  You typically can’t haggle with your insurance company over the fine print of the exclusions in your insurance policy.  Since the company can write the policy and has all the leverage compared to the policyholder, if the policy isn’t written clearly the court will read it to mean whatever a reasonable person buying insurance would expect as a matter of common sense.

The recent case Cheban v. State Farm found in favor of the policyholder by employing this rule.  Cheban made a claim under his auto insurance policy for damage to his car from an accident.  State Farm acknowledged there was coverage under Cheban’s auto policy’s Underinsured Motorist (UIM) coverage  But State Farm disputed whether the policy covered Cheban’s loss of use of his vehicle for the 47 days the car was being repaird in addition to the repair bills.

The insurance policy provided State Farm would pay “compensatory damages for property damage.”  State Farm argued this language limited State Farm’s obligation to only physical property damage, not loss of use.  Chaban argued the words “compensatory damages” expanded coverage beyond “property damage” to all resulting losses, including loss of use of the car while it was repaired.

The Washington Court of Appeals determined both State Farm’s and Cheban’s interpretations were reasonable.  Because the language was ambiguous, the court interpreted the policy consistent with Cheban’s expectations as the policyholder.  That meant Cheban was entitled to coverage for the loss of use while the car was repaired as well as the repair bill.

The Cheban v. State Farm decision is an important remind that ambiguous insurance policies will be construed in the policyholder’s favor.

Washington State Bans Surprise Medical Billing

We previously blogged about the push by Washington’s Insurance Commissioner to ban so-called surprise medical billing, i.e., where an insured gets hit with a huge bill for medical treatment despite going to an in-network provider or seeking emergency care.  In those circumstances, the insurer claims the hospital’s bill is too high and refuses to pay, and the hospital bills the patient for the difference.  This practice (known as “balance billing”) results in the policyholder getting a huge hospital bill for medical care that was covered by their insurance policy, even if the policyholder used an in-network provider and did everything right.  In these situations, the patient is stuck in the middle with the insurer and the hospital each blaming the other for the huge balance bill.

Washington’s surprise medical billing ban has now been signed into law by the Governor.  The new law is touted as one of the strongest legal protections for health insurance policyholders and patients in the country.

Among other things, the surprise medical billing ban includes the following:

  • Bans balance billing where you receive emergency medical treatment, even if it’s at an out-of-network facility – this includes seeking emergency medical treatment in a state bordering Washington State;
  • Bans balance billing where you obtain treatment from an in-network provider, regardless of whether it’s an emergency;
  • Requires insurers to pay out-of-network providers directly (as opposed to leaving the policyholder to fend for themselves.

One of the most significant reforms is that the new law requires insurers and medical providers to resolve billing disputes between themselves, rather than leaving the patient to deal with the excess bill from the provider.  This is a huge win for policyholders and patients because it means patients are no longer left holding the bag when the insurer and doctor disagree over the medical bills.  Insurers and hospitals have the resources to fight medical billing disputes and the bargaining power to keep them from happening in the first place – patients do not.  The new law fixes a major injustice by preventing insurers and providers from imposing on patients the burden of resolving medical billing disputes.

Washington’s surprise medical billing reform is a big step forward for patients and health insurance policyholders.

 

 

Insurance Tips for Wildfire Season

Washington is predicted to have a particularly severe wildfire season in 2019. Wildfires are increasing as development pushes further into wilderness areas and wildfire risk pushes into parts of Washington previously assumed to be too wet to be at risk.

Here are some tips to make sure your insurance coverage is ready for wildfire season:

  • Read your policy and confirm it covers wildfire damage.  Most homeowner’s insurance policies traditionally covered fire damage.  But some policies exclude wildfire or disaster related losses.  
  • Confirm your coverage limits are sufficient.  If you bought your home many years ago, rising property values and construction costs may render your existing coverage inadequate.
  • Make sure your policy covers your entire loss in the event of a wildfire.  For instance, confirm your policy will pay your living expenses in the event you need to relocate while your home is rebuilt (known as “Additional Living Expense” coverage).
  • Make an inventory of important and valuable contents to make sure the insurer covers the cost to replace these items in the event they are lost in a wildfire.

 

Finally, be ready to go to bat and make sure you get the coverage you are paying for.    .  After a big disaster like a wildfire, there are so many claims insurers can’t investigate them all properly, so they just stop trying.  Disaster-related insurance claims are notorious for shoddy investigating, unresponsive staff, and overworked, poorly-trained adjusters pressured to cut corners to close out claims fast.

Washington State Enacts “Public Option” Health Insurance Plan

This week, Washington State passed a new law designed to offer consumers a so-called “pubic option” for buying health insurance.  The general idea is that the state will launch its own health insurance program to compete with the marketplace.  Unlike Medicare or Medicaid, anyone would have the option to purchase coverage through the “public option.”

The public option is targeted at taking the pressure off of people who don’t receive health insurance through their employer, but make too much money to get subsidized coverage through the Affordable Care Act (a/k/a Obamacare).  Folks in this situation, often small business owners or the self-employed, have struggled with substantial premium increases in recent years.

The public option is not true insurance.  Instead, Washington State will contract with insurance companies to administer the system under the state’s control.  The main idea is that the public option caps the amount it will pay doctors, hospitals and other medical providers at 160% of the rate Medicare would pay for the same services.  Medicare rates are typically quite low compared to what an uninsured patient would pay.

The public option is hoped to avoid the steep premium increases that have become an annual routine for most health insurance.  Rates increased 13.8% in 2019; they increased 36% in 2018.

Other states, including Colorado and Connecticut, are considering similar legislation.

How Do I Know Whether To Make A Disability Insurance Claim?

Many people understand that they have disability insurance coverage, but aren’t sure whether, when, or how to make a claim.  This confusion often results in people delaying in submitting a claim, which can potentially jeopardize their right to coverage.  Below is a guide to some of the issues you might consider in determining whether to make a disability insurance claim.

First, remember that the specific insurance policy language will determine whether you have a claim for disability benefits.  Always be sure to double check the actual insurance policy language – or have a lawyer do so for you – before making any decisions.  Also be mindful that the insurance policy may be comprised of many separate documents.  For instance, there may be an insurance policy contract, declarations pages, riders, amendments, and endorsements, all contained in what might appear to be separate documents.  And if your disability coverage is subject to ERISA, other employee benefit plan documents such as a Summary Plan Description may also affect your rights.

In particular, you will want to be familiar with how the policy defines “disability.”  Most disability insurance policies define “disability” to mean, basically, you can’t work because you are ill or injured.  But the devil is often in the details.  For example, does the policy require you to be unable to do your current job, or any job within your skillset, or any job at all?  Is a software engineer with cognitive impairment from a brain injury disabled if they can still flip burgers? Slight differences in the definition of “disability” can be critical.

Second, have a clear understanding of the medical basis for your disability – i.e., the injuries, illnesses, or other conditions that affect your life and prevent you from working.  You don’t need to be a doctor to make a disability claim, but having a clear picture of the diagnoses and limitations relevant to your disability will help you submit your claim clearly.  Absent clarity, some unscrupulous insurance adjuster may try to take advantage of the confusion to mischaracterize your claim as falling within one of the policy’s exclusions.

Third, be mindful of whether you have discussed with your employer any potential accommodations that could help you perform your job despite your disability.  Most of the time, employers are legally obligated to make minor changes to your job to enable you to continue working despite your disability.  If you can keep working with a reasonable accommodation, you may not be entitled to disability insurance benefits – and may not need them in the first place!

Fourth, be mindful of any applicable time limits to make a claim.  Be sure you are submitting your claim to the right people, using the right documentation, and meeting the right deadlines.  Don’t put yourself in a position of losing out on coverage through technicalities.

These are just a few of the many things you may want to consider when deciding whether to claim disability insurance benefits.  Please keep in mind that many other issues can come into play – and the best way to protect your legal rights is to talk to a lawyer!