Articles Posted in Health Insurance

People will speak of “sticker shock” in reference to buying automobiles.  The term is also used when seeing hospital bills.  But the biggest shocker of all can be the bill for an air ambulance.

The Claims Journal published an article in February of 2018.  The article is titled, Appellate Court Rules Insurers Not On The Hook For Air Ambulance Reimbursement Rates.  It discusses a case from the Austin Court of Appeals.  Here is what it tells us.

The Austin Court of Appeals issued a decision in a case involving the high prices that air ambulances charge Texas workers’ compensation insurers.

Pursuant to the Texas Insurance Code, Section 1251.101, group accident, health, and accident and health insurance policies must contain several prescribed provisions that include the following:

  1.  premiums due must be remitted on or before the due date by the premium payors as designated in the policy and within any specified grace period;
  2.  the validity of the policy may not be contested except for nonpayment of premiums after it has been in force for two years from the date issued and that, in the absence of fraud, no statement made by any person covered by the policy relating to his or her insurability may be used in contesting the validity of the insurance with respect to which such statement was made after the insurance has been in force before the contest for two years during that person’s lifetime, nor unless it is contained in an instrument signed by him or her;

Insurance attorneys in Dallas County need to be able to know how the courts interpret exclusions in policies when the exclusions rule out coverage for injury resulting from intoxication of narcotics. The United States Western District Court in Austin issued an opinion in June of 2015, dealing with this issue. It is styled, Eleanor Crose v. Humana Insurance.

This is an adverse ruling to Crose involving a summary judgment.

Crose is insured under a health insurance policy issued by Humana. Crose suffered a stroke which left him mentally and physically impaired. He filed a claim which Humana rejected citing a policy exclusion rendering benefits non-payable when the insured’s injury is “due to being intoxicated or under the influence of any narcotic unless administered on the advice of a health care practitioner.” Crose sued for violations of the Texas Insurance Code Sections under 541.060 and 542.051.

Burleson insurance attorneys who handle health insurance situations need to read this 1989 opinion from the Houston Court of Appeals [14th Dist.]. It is styled Paramount National Life Insurance v. Williams.

On March 5, 1981, insurance agent Cliff Cox met with Frankie Williams and her husband Willie and took an application for a hospital insurance policy to be issued by Paramount. Mrs. Williams was sixty-four and had a long history of medical problems which the couple described to Cox. Cox told the Williamses he needed to know only about the preceding five years. He filled out the application and had them read and sign it. Paramount approved the application and issued the policy on March 20, 1981. Mrs. Williams was hospitalized in July 1981 and again in December 1981. She filed two claims totaling over $40,000 in connection with these hospitalizations. Paramount denied the claims and cancelled the policy on the grounds that Mrs. Williams had failed to disclose her full medical history on the insurance application and that the conditions for which she was being treated were preexisting conditions. The company refunded her premiums. Mrs. Williams then sued Paramount for breach of contract, breach of the duty of good faith and fair dealing, fraud and violations of both the Texas Insurance Code and the Texas Deceptive Trade Practices Act.

Paramount denies there was a breach of contract. It alleged that it rejected Mrs. Williams’ two hospital claims on the basis that the conditions for which she was being treated (primarily colon-related) did not comply with the definition of sickness under the policy as well as her failure to disclose preexisting medical conditions. Paramount claims that certain language in the documents relating to the policy puts the applicant on notice that accurate and complete information is required. On her application Mrs. Williams stated she was in good health and free from any physical or mental defects and her only prior medical problems were a kidney stone in 1952 and a cancerous uterus in 1975, both with full recovery. However, the evidence showed Mrs. Williams had experienced numerous physical and mental problems, including the removal of a kidney stone, colitis, possible diverticulitis, recurring pneumonia and schizophrenia. Paramount’s president testified that had the company been aware of Mrs. Williams’ complete medical history, the policy would not have been issued.

Lawyers and attorneys handling insurance claims in the Dallas and Fort Worth areas need to be able to discuss subrogation issues with clients who have been injured by third parties. Bloomberg Businessweek published an article on April 7, 2015, that discusses this issue. It is titled, “How An Insurer Is Taking Money From The Fan Beaten At Dodger Stadium.” Here is some of what it tells us.

First he was assaulted for wearing the wrong team’s clothes. Then he was sucker-punched by the insurance system.

Four years ago, Bryan Stow was a strapping paramedic who spent his days off biking with his son and daughter. That was before March 31, 2011, when he and three friends made the mistake of wearing San Francisco Giants garb to an Opening Day game against the rival Los Angeles Dodgers at Dodger Stadium. They were harassed and threatened in the stands. Afterwards, two Dodgers fans beat Stow so savagely in a parking lot that doctors had to induce a coma to save him. He was hospitalized for seven months.

Dallas insurance lawyers need to know about this ruling from the Northern District, Fort Worth Division. The case is styled, Hinna v. Blue Cross Blue Shield of Texas.

This is a lawsuit for declaratory relief filed by Kelly Hinna. Hinna sued for a declaration that Blue Cross had an obligation to pay claims under her health insurance contract and for breach of contract, violations of the Texas Insurance Code, and other causes of action. Blue Cross filed a motion for summary judgment, which was DENIED.

Hinna applied for individual health care coverage with Blue Cross and on her application gave a “No” answer to each of the following questions:

Fort Worth insurance lawyers will find the 1995, case, Darby v. Jefferson Life, useful in their insurance law practice. It is from the Houston Court of Appeals [1 Dist.].

On October 5, 1987, Jefferson Life’s agent, Charles Sharp, interviewed Darby in her home after she applied for a major medical insurance policy. Sharp read questions from the application and recorded Darby’s answers on the policy application. In one section of the document, Darby’s recorded answers showed one doctor’s visit and one hospital confinement in the previous 24 months but also showed a denial of past health problems. In another section, Darby’s recorded answers indicated she had a complete checkup during the previous month, a blood clot earlier that year, and was on medication for arthritis. Darby signed the application in two places, affirming that each answer was full, true, and complete, and agreeing that any false statement materially affecting Jefferson Life’s acceptance of the risk would render the policy void.

At trial, Darby testified that she also told Sharp, although the application did not so reflect, that she had a computerized axial tomography (CAT) scan and a magnetic resonance image (MRI) the month before her application; she had been hospitalized for a blood clot and continued to see a physician three times a week; and she had rheumatoid arthritis, which was controlled with medication. She also may have told Sharp she saw a physician once a month.

Tarrant County Insurance Lawyers will see situations where a health insurer turns down claims. Those same attorneys sue health insurance companies for mis-treating claimants. The Insurance Journal ran a story that shows the doctors doing wrong. The title of the story is, N.Y. Doctor Found Guilty In Massive No-Fault Insurance Fraud Claim.

Authorities announced that a Brooklyn, New York-based doctor has been found guilty in a no-fault insurance fraud scheme following a two-week jury trial.

According to a statement Monday from Preet Bharara, the U.S. Attorney for the Southern District of New York, Tatyana Gabinskaya was found guilty on Oct. 3 of various health care fraud and mail fraud offenses.

Irving insurance lawyers who deal with health insurance policies already know what was talked about in a recent article. The article is from FoxBusiness. Here is what the article tells us.

Few things are scarier than racking up medical bills and then learning that your health insurance company won’t pay.

It’s a nightmare that could panic any policyholder. But before you worry about sinking into a black hole of medical debt, know that federal law offers a way to appeal.

Aledo insurance attorneys are already aware of statistics reported recently by the Texas Tribune. An April 22, 2014, article tells us a half million employees in Texas are without workplace insurance. Here is what the article says.

At least a half-million Texas workers have no occupational insurance coverage, either from a state-approved workers’ compensation plan or from a private equivalent, state insurance officials said Tuesday.

The figures, provided by the Texas Department of Insurance, provoked impassioned debate at a legislative hearing about policy solutions in the only state in the country where the decision to carry workers’ compensation insurance or a private equivalent is voluntary for companies of any size.

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