- Regulators, courts and city halls are struggling to define Uber. Is it a taxi company or a technology platform?
- Ridesharing taxi services stuck in insurance limbo.
- Can insurance discounts for installing text-blocking devices lead to fewer distracted drivers?
- New U.S. laws to be considered around the use and security of Big Data from automobiles.
- The first serious accident caused by an algorithm will be a major challenge to the fully driverless future.
- California consumer watchdog wants regulator to ban insurers from using driver's occupation and education in setting rates.
.
Saturday, January 31, 2015
Insurance News - Friday, January 31, 2014
Here are the leading auto insurance headlines from ONTARIO AUTO INSURANCE TOPICS ON TWITTER for Friday, January 31, 2014:
What types of health information are consumers compelled to divulge under Affordable Care Act rules?
I just selected a new health insurance plan and they’re asking me questions about my health. I thought insurance companies can’t do this anymore?
Under health care reform laws, insurance companies can’t require you to answer health questions in order to buy insurance.
However, once you are covered by a health plan, companies are allowed to ask questions to determine whether you qualify for one of their disease management programs or for case management services. Disease management programs help consumers learn how to manage chronic health conditions such as diabetes, heart disease, or depression.
Case management programs help consumers who have very serious health conditions, such as leukemia, cut through the red tape to get the insurance company to pay for their treatment. For example, to prevent misdiagnosis, some insurance companies won’t start paying for cancer treatment until consumers get a second opinion to confirm the diagnosis. The average consumer wouldn’t know this, but a case manager will tell the consumer about this requirement and, if necessary, help the consumer schedule an appointment for a second opinion. Many case managers are also licensed nurses, so they can also suggest solutions to problems, such as side effects, that consumers experience during treatment.
Both of these services are voluntary, so you don’t have to answer the questions. Even if you do answer the questions, you don’t have to participate in the programs.
I recently applied for life insurance and they made me answer questions about my health. I thought insurance companies can’t do this anymore?
Under health care reform laws, insurance companies can’t require you answer health questions in order to buy medical insurance. However, insurance companies can still require to you answer health questions to buy other types of insurance, including:
- Life insurance
- Long-term care insurance
- Dental insurance
- Vision insurance
- Disability insurance
- Medicare Supplement plans and Medicare Advantage plans, under certain circumstances
Read more information about health care reform.
Our consumer experts can answer your questions about any type of insurance. They are available by phone at 1-800-562-6900 or by submitting an inquiry through our website.
Medicare for Young Folks: A Case Study (Part 2)
In Part 1, we met a young lady who suffered a tragic medical setback, and is now unable to live on her own, and whose medical care is paid for by Medicare. We also began to learn about what alternatives or supplements might be available to her and her family to help fund her care.
The Medicare Advantage plan seemed promising. One immediate challenge is that the most recent regular Open Enrollment period ended last month, and the next one doesn't start until the Fall. The good news, according to my personal Medicare Advantage guru Roger D, is that folks on the Extra Help program are pretty much always in Open Enrollment, so she may be able to hop on to an Advantage Plan.
So we'd now identified 3 potential avenues: an Exchange plan, her father's retirement medical plan, or a Medicare Advantage plan. It was now time to do a little more digging, and then to meet to review the results:
As it turns out, folks on Medicare can not (easily) buy an ACA Exchange policy. As the folks at CMS explain:
"It’s against the law for someone who knows that you have Medicare to sell you a Marketplace plan."
But what if you really, really want one?
Well:
"[T]here are some situations where you can choose Marketplace coverage instead of Medicare ... if you’re eligible for Medicare but haven’t enrolled in it ... If you’re paying a premium for Part A, you can drop your Part A and Part B coverage and get a Marketplace plan"
Oh. Well, our young lady is already enrolled, so the first "out" won't work. And the second alternative didn't seem very promising, since she wouldn't be eligible for a subsidy.
So much for that.
Adding her to my friend's plan has some attraction: it's a known quantity (and is itself a Medicare Advantage plan with some great benefits) and offers the convenience of having one plan (and carrier) for both.
I had, however, a concern: what happens if/when my friend passes away - can his daughter stay on the plan? After poring over the written materials he had brought with him, and several frustrating phone calls to the carrier, we still don't have a definitive answer. This is troubling, but not necessarily a deal-killer.
So we called Roger (my guru) and had a very frank and helpful discussion about a separate Medicare Advantage plan for the daughter. First, we confirmed that she is, in fact, an Extra Help participant, so the Open Enrollment issue is moot. Second, we learned that there are several $0-premium Advantage plans available here, saving my friend several thousands of dollars in extra premiums. These plans also cap her out-of-pocket exposure to about $4,000 a year, which is well within my friend's means to cover.
One thing that still needs to be done before a final decision is made is to confirm that her doctors and other providers are in-network, and to check her meds against the carriers' formulary lists.
My friend was delighted that a good plan is available at a very affordable cost ("free"), and was very impressed with Roger's depth of knowledge about not just the Advantage plans but also the Extra Help and other programs. He even suggested some other places for my friend and his daughter to look for additional resources and help.
It's such a blessing to have access to folks on whom I can call to ask for help and advice, and who I know will take care of my clients. It makes me look good (no mean feat in itself), and they get quality advice and service.
And there's this: I try to learn from every interaction I have, whether or not I make a sale. There is no doubt that I'll have the opportunity to use what I've learned on this case down the road. And that, too, is no small thing.
The Medicare Advantage plan seemed promising. One immediate challenge is that the most recent regular Open Enrollment period ended last month, and the next one doesn't start until the Fall. The good news, according to my personal Medicare Advantage guru Roger D, is that folks on the Extra Help program are pretty much always in Open Enrollment, so she may be able to hop on to an Advantage Plan.
So we'd now identified 3 potential avenues: an Exchange plan, her father's retirement medical plan, or a Medicare Advantage plan. It was now time to do a little more digging, and then to meet to review the results:
As it turns out, folks on Medicare can not (easily) buy an ACA Exchange policy. As the folks at CMS explain:
"It’s against the law for someone who knows that you have Medicare to sell you a Marketplace plan."
But what if you really, really want one?
Well:
"[T]here are some situations where you can choose Marketplace coverage instead of Medicare ... if you’re eligible for Medicare but haven’t enrolled in it ... If you’re paying a premium for Part A, you can drop your Part A and Part B coverage and get a Marketplace plan"
Oh. Well, our young lady is already enrolled, so the first "out" won't work. And the second alternative didn't seem very promising, since she wouldn't be eligible for a subsidy.
So much for that.
Adding her to my friend's plan has some attraction: it's a known quantity (and is itself a Medicare Advantage plan with some great benefits) and offers the convenience of having one plan (and carrier) for both.
I had, however, a concern: what happens if/when my friend passes away - can his daughter stay on the plan? After poring over the written materials he had brought with him, and several frustrating phone calls to the carrier, we still don't have a definitive answer. This is troubling, but not necessarily a deal-killer.
So we called Roger (my guru) and had a very frank and helpful discussion about a separate Medicare Advantage plan for the daughter. First, we confirmed that she is, in fact, an Extra Help participant, so the Open Enrollment issue is moot. Second, we learned that there are several $0-premium Advantage plans available here, saving my friend several thousands of dollars in extra premiums. These plans also cap her out-of-pocket exposure to about $4,000 a year, which is well within my friend's means to cover.
One thing that still needs to be done before a final decision is made is to confirm that her doctors and other providers are in-network, and to check her meds against the carriers' formulary lists.
My friend was delighted that a good plan is available at a very affordable cost ("free"), and was very impressed with Roger's depth of knowledge about not just the Advantage plans but also the Extra Help and other programs. He even suggested some other places for my friend and his daughter to look for additional resources and help.
It's such a blessing to have access to folks on whom I can call to ask for help and advice, and who I know will take care of my clients. It makes me look good (no mean feat in itself), and they get quality advice and service.
And there's this: I try to learn from every interaction I have, whether or not I make a sale. There is no doubt that I'll have the opportunity to use what I've learned on this case down the road. And that, too, is no small thing.
Non-profit health insurer surplus legislation advances in WA legislature
A bill we requested, Senate Bill 5247, was approved by a key state Senate committee last night.
The bill would allow us, when considering premium rates proposed by non-profit health insurers, to take into account the large surpluses that the companies have built up in recent years. (Surpluses are not the same thing as reserves. Theres' been some confusion out there on this point.)
These surpluses have grown dramatically over the past decade. The state's three major nonprofit health insurers together now have more than $2.4 billion in surplus.
Meanwhile, the cost of individual health policies more than doubled from 2005 to 2011.
At least 11 other states, including neighboring Oregon, have the authority to consider surpluses when reviewing rates. We think it's time Washington did the same.
The bill would allow us, when considering premium rates proposed by non-profit health insurers, to take into account the large surpluses that the companies have built up in recent years. (Surpluses are not the same thing as reserves. Theres' been some confusion out there on this point.)
These surpluses have grown dramatically over the past decade. The state's three major nonprofit health insurers together now have more than $2.4 billion in surplus.
Meanwhile, the cost of individual health policies more than doubled from 2005 to 2011.
At least 11 other states, including neighboring Oregon, have the authority to consider surpluses when reviewing rates. We think it's time Washington did the same.
Cavalcade of Risk #201: Call for submissions
Russell Hutchinson hosts next week's Cav. Entries are due by Monday (the 3rd).
To submit your risk-related post, just click here to email it.
You'll need to provide:
■ Your post's url and title
■ Your blog's url and name
■ Your name and email
■ A (brief) summary of the post
PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like). And please only submit if you are willing to link back to the carnival if your submission is accepted.
To submit your risk-related post, just click here to email it.
You'll need to provide:
■ Your post's url and title
■ Your blog's url and name
■ Your name and email
■ A (brief) summary of the post
PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like). And please only submit if you are willing to link back to the carnival if your submission is accepted.
What's a health care exchange?
Stateline, a news service that covers state government, put together a story summarizing the new health care exchanges scheduled to launch in 2014, how they work, and the status of the efforts to create them at the state level. From the article:
There's a tremendous amount of behind-the-scenes work taking place in Olympia in preparation for these exchanges. Again, from Stateline's article:
Considered the engines of the national health law, state exchanges are online marketplaces designed to make it easier for individuals and small businesses to shop for insurance policies. They will also be one-stop enrollment centers for low-income people who qualify for Medicaid and moderate income individuals who qualify for federal tax credits.
There's a tremendous amount of behind-the-scenes work taking place in Olympia in preparation for these exchanges. Again, from Stateline's article:
One small group of states — led by Maryland, Washington, Oregon, Rhode Island and California — is running significantly ahead of the rest. Statutes have been enacted to create the exchanges and the basic decisions about how to run them have already been made.Our office and Gov. Chris Gregoire have also requested additional exchange legislation in Washington this year.
Happy Blogiversary!
Words can't express how fortunate I feel to be working with Bob, Mike, Nate, Kelley, Bill and Pat. As I often brag, I am blessed with the very best co-bloggers on the 'Net.
Most important, of course, are our loyal readers (and followers) who visit us each day - Thank You!
Friday, January 30, 2015
Kreidler: Nearly 14.5 percent of Washingtonians were uninsured in 2012
Today, we issued our fourth report on the number of Washingtonians who have no health insurance. At the end of 2012, some 990,000 people -- approximately 14.5 percent of the state's population -- were uninsured.
From 2010 through 2012:
“For many families who have struggled to get or keep health coverage, health reform couldn’t come soon enough,” said Insurance Commissioner Mike Kreidler. “Regardless of how you feel about ‘Obamacare,’ it’s hard to argue that we’re not making progress in stopping the growth of uninsured or that the status quo was sustainable. Before health reform, we had hundreds of thousands of people living one bad diagnosis away from bankruptcy.”
From 2010 through 2012:
- The number of uninsured people in Washington grew by more than 44,000.
- Four out of five people with individual insurance were underinsured, meaning they had plans that only paid for 25-40 percent of their medical costs.
- Employer-sponsored coverage grew increasingly scarce.
- Uncompensated care ballooned to nearly $1 billion per year.
“For many families who have struggled to get or keep health coverage, health reform couldn’t come soon enough,” said Insurance Commissioner Mike Kreidler. “Regardless of how you feel about ‘Obamacare,’ it’s hard to argue that we’re not making progress in stopping the growth of uninsured or that the status quo was sustainable. Before health reform, we had hundreds of thousands of people living one bad diagnosis away from bankruptcy.”
Medicare for Young Folks: A Case Study
A friend of mine recently reached out to me for some advice about his disabled daughter. Years ago, while an Honor Student at a prestigious Midwestern university, she needed emergency surgery, and while under anesthesia, an accident occurred: oxygen was cut off to her brain for many minutes, resulting in permanent brain damage.
She is still able to converse for brief periods of time, but unable to earn a living or live on her own. Even though she's only in her early 30's, she does qualify for Medicare and for the "Extra Help" program that substantially reduced her out-of-pocket for necessary medications.
Her father - my friend - is retiring soon, and asked for my help in researching health insurance alternatives for his daughter. What he was looking for would be a pre-65 Medicare supplement (MedSupp) for her. He already knew of one potential source: for a monthly premium of $300, he could add her to his post-retirement health plan (provided by a former employer). He asked me if there were others, and I agreed to research this (mostly because I think this is a very interesting scenario, plus I get to help a friend).
I identified several potential avenues, and began to determine their viability:
First, I recalled that - years ago - the 'Medicare And You booklet' put out by our state Department of Insurance (DOI) used to include a list of the handful of carriers that sold pre-65 MedSupps. I clicked over to the site and downloaded the latest version, and began to search through it for that list.
It was nowhere to be found.
So I called the DOI to see if I was just looking past it, and was told that it wasn't me: there are currently no longer any carriers that market these plans (at least not here in the Buckeye State). So much for that.
But the nice gentleman at the DOI did mention that Medicare Advantage plans are available to serve this market, although the young lady would have to be in an Open Enrollment period. I turned to my own Medicare Advantage guru, Roger D (I long-ago decided against selling these myself), who kindly offered his expertise. One thing he suggested I do is to determine whether or not the young lady was participating in the Extra Help program.
Extra Help enables qualifying Medicare beneficiaries to purchase their meds at greatly reduced prices, with the government (well, fellow tax-payers) picking up the cost. According to the Social Security Administration (which oversees the program), Extra Help "is estimated to be worth about $4,000 peryear." Nice!
I also started looking into whether or not she could buy an ACA-plan from the Exchange.
In Part 2, we discuss the results.
She is still able to converse for brief periods of time, but unable to earn a living or live on her own. Even though she's only in her early 30's, she does qualify for Medicare and for the "Extra Help" program that substantially reduced her out-of-pocket for necessary medications.
Her father - my friend - is retiring soon, and asked for my help in researching health insurance alternatives for his daughter. What he was looking for would be a pre-65 Medicare supplement (MedSupp) for her. He already knew of one potential source: for a monthly premium of $300, he could add her to his post-retirement health plan (provided by a former employer). He asked me if there were others, and I agreed to research this (mostly because I think this is a very interesting scenario, plus I get to help a friend).
I identified several potential avenues, and began to determine their viability:
First, I recalled that - years ago - the 'Medicare And You booklet' put out by our state Department of Insurance (DOI) used to include a list of the handful of carriers that sold pre-65 MedSupps. I clicked over to the site and downloaded the latest version, and began to search through it for that list.
It was nowhere to be found.
So I called the DOI to see if I was just looking past it, and was told that it wasn't me: there are currently no longer any carriers that market these plans (at least not here in the Buckeye State). So much for that.
But the nice gentleman at the DOI did mention that Medicare Advantage plans are available to serve this market, although the young lady would have to be in an Open Enrollment period. I turned to my own Medicare Advantage guru, Roger D (I long-ago decided against selling these myself), who kindly offered his expertise. One thing he suggested I do is to determine whether or not the young lady was participating in the Extra Help program.
Extra Help enables qualifying Medicare beneficiaries to purchase their meds at greatly reduced prices, with the government (well, fellow tax-payers) picking up the cost. According to the Social Security Administration (which oversees the program), Extra Help "is estimated to be worth about $4,000 peryear." Nice!
I also started looking into whether or not she could buy an ACA-plan from the Exchange.
In Part 2, we discuss the results.
Health Wonk Review is up...
Brad Wright hosts this week's round-up of wonky health-related posts. It's quite an effort, with lots of great posts and helpful context. Do check it out.
Insurance News - Wednesday, January 30, 2013
Here are the leading auto insurance headlines from ONTARIO AUTO INSURANCE TOPICS ON TWITTER for Wednesday, January 30, 2013:
- Fraud concerns linger over Illinois driver license law that issues licenses to illegal immigrants.
- Why are drivers with clean driving records not always charged lowest auto insurance rates?
- According to Moodys, the Global economy is still a headache, but P&C insurers positioned to weather headwinds.
- Check out my article in January 2013 issue of Canadian Underwriter on regulating the towing industry in Ontario.
- Less than 20% of fraudulent insurance claims are detected or denied. Seems like we could do better.
Thursday Morning LinkFest
■ From the Stupid Carrier/Government Tricks File:
"State insurance regulators have reached a settlement with the Genworth Life Insurance Company over the insurer’s use of the Social Security Administration's Death Master File database."
The carrier has agreed to more aggressively utilize the Social Security Administration's Death Master Files (DMF) to search for potential claimants.
Only one thing wrong with this whole (stupid) idea:
As we reported almost 2 years ago, "the DMF is itself rife with potential errors and misinformation" and there's no indication that this has been addressed.
Garbage in, garbage out - but hey, at least the states' insurance departments get to nick GW's policy- and other stake-holders for some quick cash.
■ Deadlines? What deadlines?
"The IRS [has unilaterally decided that] it will wait at least until 2015 to enforce the nondiscrimination rules, at the earliest, because defining terms such as “highly compensated employee” and “discrimination” has been difficult."
Math is hard? Who knew?
More importantly, under what authority is the IRS declining to enforce the law?
■ And speaking of IRS malfeasance, turns out they're having no problem defining how to enforce theEvil Mandate ObamaTax on ordinary citizens:
"The Internal Revenue Service has drafted a collection of proposed regulations that could determine whether some taxpayers will owe fines for failing to get health coverage ... The IRS assumes many enrollees are confused"
Gee, whatever gave them that idea?
■ This is kind of scary (if unsurprising): International Medical broker Global Underwriters has provided a "brief Travel Alert Update and Product Overview for all of our brokers and agents that have clients traveling internationally."
Specifically, there are significant concerns about the upcoming Olympics, since "[a]cts of terrorism, including targeted bombings, hostage taking, suicide bombing continue to occur in Russia particularly in the North Caucasus Region."
Is this destined to be a repeat of Munich '72?
"State insurance regulators have reached a settlement with the Genworth Life Insurance Company over the insurer’s use of the Social Security Administration's Death Master File database."
The carrier has agreed to more aggressively utilize the Social Security Administration's Death Master Files (DMF) to search for potential claimants.
Only one thing wrong with this whole (stupid) idea:
As we reported almost 2 years ago, "the DMF is itself rife with potential errors and misinformation" and there's no indication that this has been addressed.
Garbage in, garbage out - but hey, at least the states' insurance departments get to nick GW's policy- and other stake-holders for some quick cash.
■ Deadlines? What deadlines?
"The IRS [has unilaterally decided that] it will wait at least until 2015 to enforce the nondiscrimination rules, at the earliest, because defining terms such as “highly compensated employee” and “discrimination” has been difficult."
Math is hard? Who knew?
More importantly, under what authority is the IRS declining to enforce the law?
■ And speaking of IRS malfeasance, turns out they're having no problem defining how to enforce the
"The Internal Revenue Service has drafted a collection of proposed regulations that could determine whether some taxpayers will owe fines for failing to get health coverage ... The IRS assumes many enrollees are confused"
Gee, whatever gave them that idea?
■ This is kind of scary (if unsurprising): International Medical broker Global Underwriters has provided a "brief Travel Alert Update and Product Overview for all of our brokers and agents that have clients traveling internationally."
Specifically, there are significant concerns about the upcoming Olympics, since "[a]cts of terrorism, including targeted bombings, hostage taking, suicide bombing continue to occur in Russia particularly in the North Caucasus Region."
Is this destined to be a repeat of Munich '72?
Tacoma insurance agent sentenced for stealing from clients
An insurance agent in Tacoma has pleaded guilty to second-degree theft for misappropriating checks from dozens of policyholders.
Michel Anthony James, an independent contractor who was working for State Farm, is believed to have deposited checks from more than 40 policyholders into his own business bank account. State Farm discovered the problems when it audited James' accounts. It subsequently terminated its contract with James.
Based on a subsequent iinvestigation by Insurance Commissioner Mike Kreidler's Special Investigations Unit, James:
• failed to apply premiums to policies,
•wrongly withdrew cash from his premium fund account (which is where those policyholder checks were supposed to go),
•failed to refund overpayments to policyholders,
•and violated contractual agreements with State Farm.
The theft added up to $23,926.87.
On Jan. 13 in Pierce County Superior Court, he pleaded guilty to second-degree theft. He was sentenced to community service, electronic home monitoring and $1,800 in costs and assessments. He has also paid back the misappropriated money.
(Updated Feb. 1 to note that James no longer works for State Farm.)
Michel Anthony James, an independent contractor who was working for State Farm, is believed to have deposited checks from more than 40 policyholders into his own business bank account. State Farm discovered the problems when it audited James' accounts. It subsequently terminated its contract with James.
Based on a subsequent iinvestigation by Insurance Commissioner Mike Kreidler's Special Investigations Unit, James:
• failed to apply premiums to policies,
•wrongly withdrew cash from his premium fund account (which is where those policyholder checks were supposed to go),
•failed to refund overpayments to policyholders,
•and violated contractual agreements with State Farm.
The theft added up to $23,926.87.
On Jan. 13 in Pierce County Superior Court, he pleaded guilty to second-degree theft. He was sentenced to community service, electronic home monitoring and $1,800 in costs and assessments. He has also paid back the misappropriated money.
(Updated Feb. 1 to note that James no longer works for State Farm.)
Insurance News - Monday, January 30, 2012
Legislation Puts Florida's No-Fault Auto Insurance Fraud on Ropes
Legislation championed by Rep. Jim Boyd of Bradenton gained momentum over the past week -- and deservedly so. With Florida serving as ground zero for staged vehicle accidents, bogus injuries and auto insurance fraud for several years now, the Legislature has tried but failed to adopt remedies. This session looks like the game-changer.
read more...
More Auto Insurance Victims Being Denied in Ontario
Insurance companies in Ontario are turning down an increasing percentage of requests for the assessment and treatment of serious injuries sustained by motor vehicle crash victims, according to a new survey.
The survey, spearheaded by the Alliance of Community Medical and Rehabilitation Providers, found that 42 per cent of requests of treatment are now being rejected, up from 11 per cent prior to the government’s changes to the insurance system in September 2010, a jump of 282 per cent. The survey looked at 1,143 rehabilitation providers, including 889 sole practitioners and 254 company/practice owners.
read more...
Ontario Court Prevents Property Transfers by Convicted Auto Insurance Fraudster
The Ontario Superior Court of Justice has upheld a summary judgment that set aside two property transfers by a convicted auto insurance fraudster over to his wife, ruling that the conveyances represented an attempt to put his assets out of "past and future victims of his fraudulent activities."
read more...
CBS Report: Scammers Cash in on Car "Accidents"
In this tough economy, one type of insurance fraud is more popular than ever. It involves scam artists who stage car crashes in order to cash in. CBS News chief investigative correspondent Armen Keteyian shows us how it works.
In Tampa, Florida, security cameras outside a business captured an accident: an SUV "slammed" into a car.
read more...
Legislation championed by Rep. Jim Boyd of Bradenton gained momentum over the past week -- and deservedly so. With Florida serving as ground zero for staged vehicle accidents, bogus injuries and auto insurance fraud for several years now, the Legislature has tried but failed to adopt remedies. This session looks like the game-changer.
read more...
More Auto Insurance Victims Being Denied in Ontario
Insurance companies in Ontario are turning down an increasing percentage of requests for the assessment and treatment of serious injuries sustained by motor vehicle crash victims, according to a new survey.
The survey, spearheaded by the Alliance of Community Medical and Rehabilitation Providers, found that 42 per cent of requests of treatment are now being rejected, up from 11 per cent prior to the government’s changes to the insurance system in September 2010, a jump of 282 per cent. The survey looked at 1,143 rehabilitation providers, including 889 sole practitioners and 254 company/practice owners.
read more...
Ontario Court Prevents Property Transfers by Convicted Auto Insurance Fraudster
The Ontario Superior Court of Justice has upheld a summary judgment that set aside two property transfers by a convicted auto insurance fraudster over to his wife, ruling that the conveyances represented an attempt to put his assets out of "past and future victims of his fraudulent activities."
read more...
CBS Report: Scammers Cash in on Car "Accidents"
In this tough economy, one type of insurance fraud is more popular than ever. It involves scam artists who stage car crashes in order to cash in. CBS News chief investigative correspondent Armen Keteyian shows us how it works.
In Tampa, Florida, security cameras outside a business captured an accident: an SUV "slammed" into a car.
read more...
Thursday, January 29, 2015
Educating Obama on Pre Existing Conditions
Now -- a pre-existing condition used to mean that someone like Amanda Shelley, a physician's assistant and single mom from Arizona, couldn't get health insurance. But on January 1st, she got covered. (Applause.) On January 3rd, she felt a sharp pain. On January 6th, she had emergency surgery. Just one week earlier, Amanda said, that surgery would've meant bankruptcy. That's what health insurance reform is all about, the peace of mind that if misfortune strikes, you don't have to lose everything.I'm glad Ms. Shelley #GotCovered. But a pre-existing condition is one that a person has prior to purchasing insurance. Her emergency surgery and sharp pain happened after she had purchased insurance.
This was not a pre-existing condition. It would have been covered before Obamacare. Likewise, under Obamacare, if Ms. Shelley wouldn't have purchased insurance on January 1st her emergency surgery would not have been covered on January 6th.
Either President Obama and his speechwriters don't understand their own law or they simply choose to lie about it. If past history is an indicator, my guess is it is the latter.
Food for thought when planning Super Bowl party
If your Super Bowl party gets out of hand or you find yourself with an unruly guest, our consumer advocates shared a general overview of what your homeowner insurance may cover. You should check your own policy to find out exactly what you are covered for.
If someone is injured at your home
Generally, homeowner policies have two types of coverage that could apply.
Premises medical (guest medical) is designed to cover medical expenses (each policy has its own limit) that occur from an on-premises, accidental injury. Premises medical is a more direct payment method to pay for, or reimburse, the injured guest for related medical expenses.
Liability would cover an injury to a guest if the homeowner was found to be negligent, and the negligence was the cause of the injury. For instance, if a homeowner failed to repair a falling-down porch and a guest was injured on it, the liability portion of the policy could cover the injury.
If a guest causes damage at your home
If an unruly guest damages your home or your belongings—such as a beer bottle launched at the TV after a bad play—it might be classified as vandalism and covered by your policy, subject to the policy deductible. The homeowner’s insurer may seek collection action against the unruly guest for reimbursement. The guest may have his or her own homeowner policy that includes liability coverage; however, it would likely not apply because intentional acts are excluded from personal liability coverage.
If you have renter insurance, check your policy for what type of damage is covered and check your lease for what type of damage you are responsible for.
Be prepared for guests
Any time you invite guests to your home, whether it be a Super Bowl party or any other gathering, it’s your responsibility to ensure your home is safe and that your guests are reasonably safe. That includes being responsible with providing alcohol to your guests, making sure there are no obvious hazards and generally taking the same precautions for your guests’ safety as you do for your own.
Before the game, talk to your insurance agent about what is and what is not covered in your policy.
You can find more information about home insurance on our website.
Enjoy the Super Bowl and go Seahawks!
PPACA - governing arbitrarily rather than lawfully.
Via the indispensable Overlawyered comes this article published in the Journal Regulation:
You’ll find it well worthwhile to read the entire article, but here are its concluding paragraphs:
You’ll find it well worthwhile to read the entire article, but here are its concluding paragraphs:
"In his classic 1964 book The Morality of Law, Harvard legal philosopher Lon Fuller listed several criteria that mark the break-down of the rule of law. They include the lack of rules, leading to inconsistent decisions; rules that are secret or unintelligible; the use of retroactive legislation; commands requiring citizens to do the impossible; edicts that change unpredictably; and a gap between the rules and the way government actually operates. A society suffering from those maladies is likely to be governed arbitrarily, rather than lawfully.Shall Americans accept such assaults on the Constitution and the rule of law, by following this increasingly tinpot President down the rabbit hole of unilateral government thru arbitrary enforcement and Executive Orders? Sadly, this remains an open question.
"Sadly, even in its early stages, PPACA already manifests many of those symptoms. It left many crucial terms unexplained; even “minimum essential coverage”—i.e., what kind of insurance the law requires Americans to purchase—was left for HHS bureaucrats to define later, outside the reach of the ballot box. The employer mandate was unilaterally extended by administrative fiat beyond the statute’s clear command—yet Republican demands for a similar extension of the individual mandate were turned away, only to be granted in a modified form weeks later when HealthCare.gov proved a failure.
"Those and other aspects of the legislation’s halting and unpredictable implementation reveal serious flaws in PPACA. But they also demonstrate a deeper crisis.
"In the pursuit of progressive goals, the Obama administration and its congressional allies have done long-lasting damage to a constitutional order that was meant to preserve individual liberty by cabining government power along clear, predictable, and democratically accountable lines."
Anti-Fraud Regulations Come Into Effect June 1
The Ontario Government has made public the regulatory changes that will be made to help combat auto insurance fraud. The changes were approved on January 21, 2013 and are scheduled to come into effect on June 1, 2013.
Regulation 14/13 amends the Statutory Accident Benefits Schedule (SABS) - 34/10.
The amendments to the SABS include:
The Cost of Goods Guideline was issued by FSCO in January 2012.
FSCO also plans to issue a standard form prior the regulation coming into effect that insurers will be required to use for the purposes of the bi-monthly benefit statements to claimants.
Regulation 15/10 amends the Unfair or Deceptive Acts or Practices (UDAP) Regulation - 7/00.
The changes to the UDAP regulation include:
Regulation 16/13 amends the Disputes Between Insurers (DBI) Regulation - 283/95.
The amendment to the DBI regulation allows for the insurer that receives the initial application for benefits to request one examination of the claimant under oath to assist in the determination of priority issues.
This amendment provides insurers with a second opportunity to request a claimant undergo an examination under oath. The new DBI requirement is to assist an insurer to determine which insurer is liable to pay the claimant accident benefits. The SABS provisions continues to assist an insurer to determine whether the claimant entitled to accident benefits.
Regulation 14/13 amends the Statutory Accident Benefits Schedule (SABS) - 34/10.
The amendments to the SABS include:
- a requirement for insurers to provide all reasons when denying medical and rehabilitation claims;
- providing FSCO with authority to stipulate additional information that insurers must provide in bi-monthly benefit statements to claimants;
- giving insurers authority to require claimant confirmation of receipt of goods and services that have been billed; and
- providing FSCO with authority to stipulate by Guideline the maximum payable by insurers for goods as well as services.
The Cost of Goods Guideline was issued by FSCO in January 2012.
FSCO also plans to issue a standard form prior the regulation coming into effect that insurers will be required to use for the purposes of the bi-monthly benefit statements to claimants.
Regulation 15/10 amends the Unfair or Deceptive Acts or Practices (UDAP) Regulation - 7/00.
The changes to the UDAP regulation include:
- an offence to request, require or permit a claimant to sign an incomplete claim form and
- clarifying the exemption for lawyers and paralegals to ensure the regulation applies to lawyers and paralegals when not acting in a legal capacity.
Regulation 16/13 amends the Disputes Between Insurers (DBI) Regulation - 283/95.
The amendment to the DBI regulation allows for the insurer that receives the initial application for benefits to request one examination of the claimant under oath to assist in the determination of priority issues.
This amendment provides insurers with a second opportunity to request a claimant undergo an examination under oath. The new DBI requirement is to assist an insurer to determine which insurer is liable to pay the claimant accident benefits. The SABS provisions continues to assist an insurer to determine whether the claimant entitled to accident benefits.
Wednesday, January 28, 2015
Insurance News - Monday, January 28, 2013
Here are the leading auto insurance headlines from ONTARIO AUTO INSURANCE TOPICS ON TWITTER for Monday, January 28, 2013:
- Consumer Federation of America Report: Largest auto insurers often charge higher premiums to safe driver.
- Multitasking and Distracted Driving: You Are Not the Exception.
- Most brokers are not using basic social media platforms: Twitter, Facebook, Google search engine, blogs.
- Liability Issues Create Potholes on the Road to Driverless Cars.
FSCO Arbitrator Further Clarifies Meaning of 'Economic Loss'
In the recent case of Simser and Aviva (FSCO A11-004610, January 16, 2013), Arbitrator Lee examined the meaning of “economic loss” in s. 3(7)(e) of the SABS.
The insured provided a report from an economist regarding the definition of “economic loss”. He argued that since it was not defined in the SABS it should be defined to include “opportunity cost”, as well as loss of time devoted to labour or leisure. The arbitrator indicated that if a broad interpretation of "economic loss" was accepted, it would negate the intent of introducing the amendment. The outcome would be no change to the interpretation prior to September 1, 2010.
Aviva argued that economic loss should mean a financial or monetary loss. The arbitrator rejected the insured’s argument and accepted that of the insurer. As a result, he concluded that no economic loss was sustained and as such the claimed benefits were rejected.
The insured had applied for attendant care and housekeeping benefits following his accident of November 10, 2010. None of the three providers provided supporting documentation to that would have demonstrated an actual loss. The only witness was vague and was unable to sufficiently support the claims.
The significance of this decision is that it recognizes that the amendment made in September 1, 2010 was intended to narrow the interpretation of incurred expense. For an expense to have been incurred:
(1) the insured person has received the services;
(2) the insured person has paid or promised to pay or is otherwise legally obligated to pay the expense; and
(3) the person who provided the goods or services:
The insured provided a report from an economist regarding the definition of “economic loss”. He argued that since it was not defined in the SABS it should be defined to include “opportunity cost”, as well as loss of time devoted to labour or leisure. The arbitrator indicated that if a broad interpretation of "economic loss" was accepted, it would negate the intent of introducing the amendment. The outcome would be no change to the interpretation prior to September 1, 2010.
Aviva argued that economic loss should mean a financial or monetary loss. The arbitrator rejected the insured’s argument and accepted that of the insurer. As a result, he concluded that no economic loss was sustained and as such the claimed benefits were rejected.
The insured had applied for attendant care and housekeeping benefits following his accident of November 10, 2010. None of the three providers provided supporting documentation to that would have demonstrated an actual loss. The only witness was vague and was unable to sufficiently support the claims.
The significance of this decision is that it recognizes that the amendment made in September 1, 2010 was intended to narrow the interpretation of incurred expense. For an expense to have been incurred:
(1) the insured person has received the services;
(2) the insured person has paid or promised to pay or is otherwise legally obligated to pay the expense; and
(3) the person who provided the goods or services:
(i) did so in the course of the employment, occupation or profession in which he was ordinarily engaged, but for the accident; orIn this particular case, part 3 of the definition was not met.
(ii) the person sustained an economic loss as a result of providing those goods or services to the insured person.
Down to the wire...
From Anthem email:
"Reminder: January 31 is payment deadline for individual plans effective January 1
Consumers who purchased an individual health plan with a January 1 effective date have until January 31 to submit payment for their first months premium. This applies to individual plans bought on or off the exchange."
One wonders how many will comply, and what happens to those who don't. Recall, also, that the original deadline was the 1st. How many more extensions will Ms Shecantbeserious approve?
"Reminder: January 31 is payment deadline for individual plans effective January 1
Consumers who purchased an individual health plan with a January 1 effective date have until January 31 to submit payment for their first months premium. This applies to individual plans bought on or off the exchange."
One wonders how many will comply, and what happens to those who don't. Recall, also, that the original deadline was the 1st. How many more extensions will Ms Shecantbeserious approve?
Insurance News - Tuesday, January 28, 2014
Here are the leading auto insurance headlines from ONTARIO AUTO INSURANCE TOPICS ON TWITTER for Tuesday, January 28, 2014:
- Ontario-based insurers paid more than $25 million in claims for vehicles damaged in the December ice storms.
- Is the state of Ontario auto causing foreign property and casualty insurers to reconsider their business strategy in Canada?
- FSCO has released a revised MIG and OCF-18 to reflect SABS changes that become effective on February 1st.
- In Florida Personal Injury Protection coverage is projected to drop an average of 13.2% from a year ago because of anti-fraud reforms. However, the overall reduction is only 1.2% because “no-fault” accounts for a small portion of auto coverage.
- With a spring provincial election still a strong possibility, a Forum poll from the weekend shows Conservatives at 36%, Liberals at 33% and the NDP at 26% as polling numbers show the race is even tighter.
When you've lost Jim Moran...
Congresscritter Jim Moran (D-Va) is concerned:
"I’m afraid that the millennials, if you will, are less likely to sign up [for the ObamaTax] ... don’t think we’re going to get enough young people signing up to make this bill work as it was intended to"
Here's the point, to which Rep Moran passingly alludes: in order for the numbers to properly crunch, there has to be a mix of both healthy and young people (not necessarily the same thing). Absent one, or both, the system will quickly fall apart, since it's on the shoulders of those two demographics that the premium structure relies.
How's that, you ask?
It's pretty simple, really: since the ObamaTax limits the premium differential between young and old, the former are needed to subsidize the costs of the latter. This means that young people will pay disproportionately higher premiums in order to artificially lower the folks in their 40's and 50's.
And since the law now requires that insurers take everyone whop comes a-callin' - and the sicker the better, really, for the photo ops - the healthiest are now subsidizing their less fortunate fellows to an even greater extent than under our previous system.
What's that word I'm looking for? Oh, yeah.
"I’m afraid that the millennials, if you will, are less likely to sign up [for the ObamaTax] ... don’t think we’re going to get enough young people signing up to make this bill work as it was intended to"
Here's the point, to which Rep Moran passingly alludes: in order for the numbers to properly crunch, there has to be a mix of both healthy and young people (not necessarily the same thing). Absent one, or both, the system will quickly fall apart, since it's on the shoulders of those two demographics that the premium structure relies.
How's that, you ask?
It's pretty simple, really: since the ObamaTax limits the premium differential between young and old, the former are needed to subsidize the costs of the latter. This means that young people will pay disproportionately higher premiums in order to artificially lower the folks in their 40's and 50's.
And since the law now requires that insurers take everyone whop comes a-callin' - and the sicker the better, really, for the photo ops - the healthiest are now subsidizing their less fortunate fellows to an even greater extent than under our previous system.
What's that word I'm looking for? Oh, yeah.
Tuesday, January 27, 2015
Tacoma man pleads guilty to forgery and insurance fraud
A Tacoma man has pleaded guilty to two counts of forgery and one count of felony insurance fraud for filing a false auto insurance claim.
Cash B. Knott, 46, pleaded guilty Jan. 13 in Pierce County Superior Court.
On Nov. 6th, less than a month after getting coverage from Progressive Direct Insurance Co. for his 1992 Ford Ranger pickup, Knott filed a $5,674 insurance claim with Progressive. He said someone had scratched the paint, stolen his chrome wheels and tires, and stolen his navigation and entertainment system, 1,000 watt amplifier and other electronic components.
He provided Progressive with a Sept. 2 stereo shop invoice for $4,547.84 worth of stereo equipment, a copy of his check, and a bank statement showing the withdrawal from his checking account.
The problem: When contacted by an insurance adjuster, the stereo shop said it had no record of such a purchase. All they could find was that Knott had bought an amplifier -- for $109 -- on Sept. 2.
Insurance Commissioner Mike Kreidler's Special Investigations Unit obtained a search warrant for Knott's bank records. The bank found no checks written to the stereo shop, and none whatsoever for $4,547.84.
He's slated for sentencing on Feb. 17th. The standard range for the charges are 22 to 29 months in prison.
Cash B. Knott, 46, pleaded guilty Jan. 13 in Pierce County Superior Court.
On Nov. 6th, less than a month after getting coverage from Progressive Direct Insurance Co. for his 1992 Ford Ranger pickup, Knott filed a $5,674 insurance claim with Progressive. He said someone had scratched the paint, stolen his chrome wheels and tires, and stolen his navigation and entertainment system, 1,000 watt amplifier and other electronic components.
He provided Progressive with a Sept. 2 stereo shop invoice for $4,547.84 worth of stereo equipment, a copy of his check, and a bank statement showing the withdrawal from his checking account.
The problem: When contacted by an insurance adjuster, the stereo shop said it had no record of such a purchase. All they could find was that Knott had bought an amplifier -- for $109 -- on Sept. 2.
Insurance Commissioner Mike Kreidler's Special Investigations Unit obtained a search warrant for Knott's bank records. The bank found no checks written to the stereo shop, and none whatsoever for $4,547.84.
He's slated for sentencing on Feb. 17th. The standard range for the charges are 22 to 29 months in prison.
Timing is everything
This past Fall, I had the opportunity to help one of my long-time clients - who's also a good friend - buy some additional life insurance. My friend, we'll call him Ted, is a bit, um, portly, so he didn't qualify for the best rates. Still, he was satisfied with the offer that the carrier tendered, and we secured the coverage.One evening recently, Ted called me at home with some scary news: he was calling from the hospital, where he had just been admitted because they had found what appeared to be a brain tumor. Surgery was scheduled for the next day, and he didn't want me to hear the news from a third party.
Of course, I wished him well, and asked if there was anything I could do for him or his family. Mostly, he said, send good thoughts and prayers that the surgery would be successful, and that it would turn out to be something treatable. Of course I agreed.
He did have the surgery, and we're still waiting on the results. In the meantime, though, I immediately went back and reviewed the recent application and coverage binder to be sure that all the i's were crossed and t's dotted. This is especially critical in a case such as this: life insurance policies have a one- or two-year "contestability" clause (often erroneously referred to as a "suicide clause"). Briefly, the contestability clause allows the carrier to review a recently approved policy to see if there were any misstatements or misrepresentations, or if relevant information was omitted (such as a history of cancer).
Thankfully, none of that appears to be the case and, since I've known Ted for over 20 years, I think I'd have a pretty good idea if he had skipped anything important on the application.
Here's why I'm so grateful that he agreed to the final rate: for at least the next few years, Ted isn't going to be able to buy any additional life insurance and will likely never qualify again for even these rates.
Sometimes, it pays to listen to your agent.
What to do if you haven’t received your proof of medical insurance
Some Washington health-care enrollees have not yet received proof of their insurance coverage. As a result, many consumers are unsure if their medical treatments are covered. If you recently bought a plan, but still haven’t received proof of insurance from your insurance company, Insurance Commissioner Mike Kreidler offers these tips.
Since open enrollment began on Oct. 1, insurance companies have encountered multiple problems that have prevented them from being able to enter new members into their systems. Some companies received incomplete or incorrect information from the insurance marketplaces. Other companies were overwhelmed with the number of applications they received and were unable to process them by the time the new plans went into effect. This delay in providing proof of coverage has many consumers worrying if they really have insurance and wondering what to do next.
Contact the company
The first thing you should do is contact your insurance company to verify that you do have insurance coverage. Ask your company for proof of coverage, such as an insurance card or identification numbers. When you speak to your company, take detailed notes of the conversation. Include the date and time that the conversation took place, and the name of the representative you speak to. Keep copies of any written communication you receive, such as emails or letters. You may need these materials later.
If you are not sure how to contact your plan, our website has contact information for each of the insurance companies that sells plans through Washington Healthplanfinder.
You should also verify that you have paid your first premium on time. Some insurers have permitted late payments for coverage retroactive to Jan. 1. Find out your insurer’s deadline and keep any records that can serve as proof of payment.
If you are about to buy coverage from Washington Healthplanfinder, print any paperwork or confirmations that you receive during the enrollment process.
If you know you don’t qualify for a subsidy through Washington Healthplanfinder, you may find it easier to buy insurance directly a broker or an insurance company. Here’s a list of the plans that are available in Washington.
Remember, 2014 open enrollment for most plans ends on March 31.
Payment options
You may need to get a prescription filled or see your doctor before you receive your insurance card. Your medical provider (hospital, doctor, pharmacy) may be able to verify your coverage by contacting your insurer directly. If they cannot verify your coverage cannot be obtained, you still have options.
One option is to pay for expenses out of pocket. Once your insurance coverage is established, your insurance company should reimburse you in accordance with its established fees for services, minus any deductibles and copayments you are responsible for.
You may also be able to work with your doctor’s office, hospital or pharmacy to delay payment or set up a payment plan until they can verify that you’re insured. Keep your receipts and any bank statements that show that you’ve paid for the services.
More information
The Insurance Commissioner doesn’t administer Washington Healthplanfinder, so if you purchased insurance there, your best bet is to contact their customer service staff if you have questions about whether you are covered.
Since open enrollment began on Oct. 1, insurance companies have encountered multiple problems that have prevented them from being able to enter new members into their systems. Some companies received incomplete or incorrect information from the insurance marketplaces. Other companies were overwhelmed with the number of applications they received and were unable to process them by the time the new plans went into effect. This delay in providing proof of coverage has many consumers worrying if they really have insurance and wondering what to do next.
Contact the company
The first thing you should do is contact your insurance company to verify that you do have insurance coverage. Ask your company for proof of coverage, such as an insurance card or identification numbers. When you speak to your company, take detailed notes of the conversation. Include the date and time that the conversation took place, and the name of the representative you speak to. Keep copies of any written communication you receive, such as emails or letters. You may need these materials later.
If you are not sure how to contact your plan, our website has contact information for each of the insurance companies that sells plans through Washington Healthplanfinder.
You should also verify that you have paid your first premium on time. Some insurers have permitted late payments for coverage retroactive to Jan. 1. Find out your insurer’s deadline and keep any records that can serve as proof of payment.
If you are about to buy coverage from Washington Healthplanfinder, print any paperwork or confirmations that you receive during the enrollment process.
If you know you don’t qualify for a subsidy through Washington Healthplanfinder, you may find it easier to buy insurance directly a broker or an insurance company. Here’s a list of the plans that are available in Washington.
Remember, 2014 open enrollment for most plans ends on March 31.
Payment options
You may need to get a prescription filled or see your doctor before you receive your insurance card. Your medical provider (hospital, doctor, pharmacy) may be able to verify your coverage by contacting your insurer directly. If they cannot verify your coverage cannot be obtained, you still have options.
One option is to pay for expenses out of pocket. Once your insurance coverage is established, your insurance company should reimburse you in accordance with its established fees for services, minus any deductibles and copayments you are responsible for.
You may also be able to work with your doctor’s office, hospital or pharmacy to delay payment or set up a payment plan until they can verify that you’re insured. Keep your receipts and any bank statements that show that you’ve paid for the services.
More information
The Insurance Commissioner doesn’t administer Washington Healthplanfinder, so if you purchased insurance there, your best bet is to contact their customer service staff if you have questions about whether you are covered.
What are my odds of dying from...?
The Insurance Information Institute has released some interesting data about the odds of dying in a wide variety of accidental (or sometimes not-so-accidental) injuries.
According to the III, your odds of dying from:
See the link above for more examples.
According to the III, your odds of dying from:
- A car accident: 1 in 303.
- Being shot: 1 in 306.
- Falling down the stairs: 1 in 2,018.
- An airplane crash: 1 in 7,032.
- Falling off a ladder: 1 in 8,912
- A lightning strike: 1 in 84,079.
See the link above for more examples.
Monday, January 26, 2015
Personal Injury Lawyer Launches a Constitutional Challenge Against Bill 15
Joseph Campisi, a Toronto area personal injury has launched a constitutional challenge to Bill 15, Fighting Fraud and Reducing Auto Insurance Rates Act, 2014. The bill received Royal Assent in November 2014 and introduces a number of changes to the auto insurance system including:
- moving SABS disputes to the Licence Appeal Tribunal
- introduce regulation to the towing and vehicle storage industries
- authorize the province to reduce vehicle storage costs.
Joseph Campisi, lawyer and advocate, is launching a constitutional challenge in the Ontario Superior Courts. Mr. Campisi is seeking a declaration from the courts that parts of the legislation that were recently passed by the Liberal Government are discriminatory and unconstitutional and should be inoperative.
“The right to access the Superior Courts is a fundamental right for Canadians. I am concerned that the recently proclaimed legislation will deny this right to individuals who have been severely disabled.” said applicant and noted Personal Injury Lawyer Joseph Campisi. “Historically, the deck has been stacked against collision victims. The recent amendments to the legislation have turned a bad situation into a worse one for these vulnerable individuals. No longer will these individuals be allowed to have the assurance of impartiality and independence that is a cornerstone of our justice system when litigating a claim against their own insurance company. I could not stand idly by and let this happen.”
In the fall, of 2014, the Ontario Government passed Bill 15 which is titled Fighting Fraud and Reducing Automobile Insurance Rates. One of the legislative amendments changes how disputes between insurers and insured are settled. Historically, disputes could be brought before the Superior Courts or before sophisticated arbitrators with expertise in interpreting insurance law. Bill 15 has changed how disputes are resolved by giving the sole adjudicative power to individuals who will be appointed at the whim of the Liberal Government. These are the same decision makers who have jurisdiction on matters ranging from film classification to upholstered and stuffed articles. Unlike historical appointments, individuals without any specialization or guaranteed independence or impartiality will be ruling on disputes that can run into the millions of dollars and will determine the quality of life that an automobile victim will face going forward.
“This application will challenge Bill 15 on the basis that it violates disabled persons’ Chapter s.15(1) right to be free from discrimination. Bill 15 is also being challenged based on s.96 of the Constitution which relates to the public’s right to have access to the courts. The way in which Bill 15 is drafted opens the door to political interference. The government of the day can choose who will hear any dispute and if the government does not agree with the arbitrator’s decisions, the government can get rid of the adjudicator the next day. When it comes to lobbying the government there is little doubt as to who has the deeper pockets- automobile insurers or accident victims. Introducing such laws is undemocratic and detracts from the rule of law. This legal challenge will fight for disabled individuals’ right to fair treatment and the public’s right to access the impartial court system.”
Insurance News - Saturday, January, 26, 2013
Here are the leading auto insurance headlines from ONTARIO AUTO INSURANCE TOPICS ON TWITTER for Saturday, January 26, 2013:
- Thinking of starting a diet? A new study concludes that obese drivers are more likely than normal weight drivers to die in a car crash.
- A J.D. Power study indicates that auto insurance claims satisfaction climbs as payment times decrease.
- Telematics could change how personal insurance is sold.
- State Farm Rapidly Expands its Usage-Based Insurance Program in the U.S.
- Haven't seen a car pile up like this one in a quite a while: Major Highway 401 crash near Newcastle involves up to 80 vehicles, some people critically injured.
MVNHS© vs Seniors
This is the future of the ObamaTax, as well:
"Pensioners with cancer are being written off as too old to treat ... survival rates for British patients aged 75 and over are among the worst in Europe."
And younger Brits with cancer aren't faring so well, either:
"Young lung cancer sufferers are only 10 per cent more likely to die within five years than their continental counterparts"
Gotta love that "only" qualifier.
"Pensioners with cancer are being written off as too old to treat ... survival rates for British patients aged 75 and over are among the worst in Europe."
And younger Brits with cancer aren't faring so well, either:
"Young lung cancer sufferers are only 10 per cent more likely to die within five years than their continental counterparts"
Gotta love that "only" qualifier.
Anti-fraud group releases its "Hall of Shame" for 2011
The Coalition Against Insurance Fraud has compiled its annual "Insurance Fraud Hall of Shame" list. And this batch is pretty horrifying:
- A debt-plagued Arizona homeowner torched his home for $440,000 in insurance money -- and killed a witness and the witness' family. He got 14 years in prison for the insurance fraud, and the death sentence for the murders.
- A Rhode Island radio DJ who wanted to upgrade her home and pool had several friends simulate storm damage to her home -- smashing a hole in her roof with a tree limb, messing up the pool, etc. The problem: The weather was fair and in the 70s that day. And one of the DJ's accomplices was caught on an unrelated federal wiretap bragging about the job.
- Another home-arson case involved a California couple who hired a man to burn down their home. The man used a lot of gasoline, leading to a blast that left him horribly burned. He died later that day. The couple went to prison.
- There are several others, but we'll end with what's probably the strangest case. A mortuary workers and medical worker faked the death of a man who'd never existed. There was even a grave. And a funeral service. Using forged documents, the workers and accomplices had taken out $950,000 in life insurance policies on the fictitious man.
Sunday, January 25, 2015
Long-term care insurance: Is it right for you?
Kaiser Health News and the Washington Post have an article today on the pros and cons of long term care insurance. From the article:
In recent years, we've received numerous complaints about the cost of the policies. Long term care insurance is a fairly new product, with many companies not offering it until the early 1990s. As a result, they had little experience to base their prices on, and early policies were priced significantly lower than they should have been, based on how the cost of claims and the fact that -- unlike life insurance, for example -- few people cancel the policies.
As a result, most long-term care insurers have bumped up their premiums sharply in the past few years -- in some cases 40 percent or more -- angering customers who signed up for policies at relatively low cost years ago. This is a problem across the country. Again, from the article:
The question of whether to get long-term care insurance bedevils consumers and their advisers. Unlike medical insurance, it is intended primarily to cover people who need assistance with so-called activities of daily living -- for example, the care of a dementia patient or someone recovering from a broken hip. It can be expensive: Premiums range from $1,000 to $5,000 a year, depending on the age, sex and health of the purchaser as well as the extent of the coverage. And policy details can be confusing.
Even advocates acknowledge that it isn't for everyone. Jesse Slome, executive director of the American Association for Long-Term Care Insurance, an industry group, sums it up well: "Long-term care is a universal issue facing all Americans who are getting older. But long-term-care insurance is not a universal solution."Many people think that their health insurance will cover long term care, but most don't. Nor do Medicare or Medicare supplemental policies. Medicaid will pay, but to qualify for Medicaid, your assets must dwindle away to almost nothing.
In recent years, we've received numerous complaints about the cost of the policies. Long term care insurance is a fairly new product, with many companies not offering it until the early 1990s. As a result, they had little experience to base their prices on, and early policies were priced significantly lower than they should have been, based on how the cost of claims and the fact that -- unlike life insurance, for example -- few people cancel the policies.
As a result, most long-term care insurers have bumped up their premiums sharply in the past few years -- in some cases 40 percent or more -- angering customers who signed up for policies at relatively low cost years ago. This is a problem across the country. Again, from the article:
"It's probably the most frequent complaint I hear," says (Kansas Insurance Commissioner Sandy) Praeger, who heads the National Association of Insurance Commissioners' health and managed care committee. "The problem is, the older policies weren't priced right to begin with. Companies expected about 8 percent of customers to stop paying their premiums, when, in fact the lapse rate is closer to 2 percent." That meant the insurers had to cover more beneficiaries than they expected at a time when the economic downturn has meant less returnon their investments.
Praeger acknowledges that rate increase requests have posed a dilemma for insurance commissioners. "If we don't give them the rate increase they need, the insurance carriers could become financially impaired, and that doesn't help people," she says. In fact, in recent years, a number of companies have stopped selling policies. As a result, she adds, it's hard to turn the increases down.
Insurer fined $100,000
A company that issued thousands of medical insurance policies to college students has been fined $100,000 for charging unapproved rates, as well as other violations.
Indiana-based Unicare Life and Health Insurance Co. has agreed to pay the fine.
Between mid-2004 and mid-2009, Unicare sold thousands of medical insurance policies to students at community colleges, technical schools, colleges and universities across Washington state. Insurance Commissioner Mike Kreidler’s office later determined that there were substantial problems with the coverage. Among them:
• For more than six years, the company used unapproved methods to set its rates.
• Unicare continued to wrongly cite a policy exclusion for 5 years after the law had changed to ban insurers from using the exclusion.
• Unicare allowed unlicensed insurance agents to market and sell the policies. The primary company marketing the policies was not licensed to do business in Washington until June 2009. At that point, it had been selling the policies for four years.
The company was unable to respond to Kreidler’s requests for supporting documentation on rates at specific colleges, saying that the documents were prepared by employees who no longer worked there.
Fines collected by the insurance commissioner’s office do not go to the agency. The money is deposited in the state’s general fund to pay for other state services.
The policies included international students at the University of Washington, Washington State University, Bellevue Community College, Seattle Pacific University, Shoreline Community College, Tacoma Community College and South Puget Sound Community College, among others.
Indiana-based Unicare Life and Health Insurance Co. has agreed to pay the fine.
Between mid-2004 and mid-2009, Unicare sold thousands of medical insurance policies to students at community colleges, technical schools, colleges and universities across Washington state. Insurance Commissioner Mike Kreidler’s office later determined that there were substantial problems with the coverage. Among them:
• For more than six years, the company used unapproved methods to set its rates.
• Unicare continued to wrongly cite a policy exclusion for 5 years after the law had changed to ban insurers from using the exclusion.
• Unicare allowed unlicensed insurance agents to market and sell the policies. The primary company marketing the policies was not licensed to do business in Washington until June 2009. At that point, it had been selling the policies for four years.
The company was unable to respond to Kreidler’s requests for supporting documentation on rates at specific colleges, saying that the documents were prepared by employees who no longer worked there.
Fines collected by the insurance commissioner’s office do not go to the agency. The money is deposited in the state’s general fund to pay for other state services.
The policies included international students at the University of Washington, Washington State University, Bellevue Community College, Seattle Pacific University, Shoreline Community College, Tacoma Community College and South Puget Sound Community College, among others.
FSCO Has Released a Revised MIG and OCF-18
FSCO has releasing a revised Minor Injury Guideline (MIG) and Treatment and Assessment Plan (OCF-18) that become effective February 1, 2014.
The revised MIG and OCF-18 reflect the recent change made to the SABS in which a pre-existing condition must have been documented by a health practitioner prior to the accident. The change is reflected in Section 4 of the MIG which deals with impairments that do not fall under the guideline. As for the OCF-18, changes have been made to the introductory Note box on page 1 and to the second question in Part 4.
Revised MIG is here.
Revised OCF-18 is here.
SABS amendment to section 38 (3) (c) (i) is found here.
Texting Also Distracts Pedestrians
A woman distracted by a text fell feet-first into a frozen canal in Birmingham — and the entire incident was caught on tape by one of England's many CCTV cameras.
Laura Safe, a newsreader for the Capital FM Breakfast Show, later joked about the tumble on Twitter, saying she "should really be called Laura UNsafe after the day I've had."
Lets hope Laura doesn't do this behind the wheel.
Laura Safe, a newsreader for the Capital FM Breakfast Show, later joked about the tumble on Twitter, saying she "should really be called Laura UNsafe after the day I've had."
Lets hope Laura doesn't do this behind the wheel.
Obamacare Success in Illinois
Amidst broken websites, and broken promises, apparently #Obamacare is working well in the land of Lincoln.
The Illinois Medicaid program received the first 5,000 of those Medicaid applications from the federal government Thursday, said Mike Koetting of the Illinois Department of Healthcare and Family Services, the state's Medicaid agency. Federal officials have informed Illinois there will be 76,000 total applications representing 110,000 individuals, Koetting said.
"That will completely swamp us," Koetting said at a meeting of state health officials in Chicago. Illinois Department of Human Services Secretary Michelle Saddler agreed, saying the incoming applications will "create major problems" and that her agency, which processes the applications, had "a gargantuan task ahead of us."
Mike Claffey, a spokesman for the Illinois Medicaid program, said the state is hiring additional workers and hiring temporary workers to keep up with the expected load.
I guess Obamacare isn't the jobs killer it has been billed to be.
Saturday, January 24, 2015
Today, I spent three hours listening to Anthem's on-hold music...
Somewhere, in one of the deepest circles of Hell, Anthem's over modulated, distorted, horrible music is playing...for eternity. Be good. Or else....
Insurance Commissioner's 2014 legislative priorities
The 2014 legislative session started on January 13. It’s a short session, scheduled to conclude March 13.
This year, the Office of the Insurance Commissioner has two important legislative priorities.
Insurance Company Solvency (HB 2461)
We're seeking to adopt two model acts created by the National Association of Insurance Commissioners (NAIC) in response to the global financial crisis.
One, called the Holding Company Act, enhances our ability to oversee, monitor and regulate any company under a parent company or holding company system. It must be adopted by Jan. 1, 2016, or Washington state risks losing its NAIC accreditation. This model act aims to improve transparency and accountability of companies and conglomerates that own insurance companies. The legislation would also prevent firms from circumventing regulation designed to protect against financial shell games that could result in insolvency.
The other is called the Own Risk and Solvency Assessment (ORSA) Model Act and requires companies to create a plan for self-assessing and reporting their current and future financials in light of their two- to five-year business plans.
Alien Insurer State of Entry (HB 1402/SB 5489)
This bill modernizes the terms under which international insurance companies could enter the U.S. insurance market through Washington state and requires them to meet the same financial-strength standards and play by the same rules.
K-12 Data Study Funding Restoration
The Legislature passed SB 5940 in 2012, requiring our office to annually study and report on K-12 employee benefits. The original bill included an appropriation of $1.3 million, but the funding was cut last year to $300,000. Without restored funding, we cannot complete the study. This bill restores the funding to its original appropriation.
We post this information on our legislative priorities page.
Public comment on bills
The state Legislature’s website has a new feature that allows citizens to comment on bills. All comments are emailed to all state legislators. If you are interested in commenting on these bills or any others that are being considered, you can search for the bill and select “comment on this bill” next to the bill number.
This year, the Office of the Insurance Commissioner has two important legislative priorities.
Insurance Company Solvency (HB 2461)
We're seeking to adopt two model acts created by the National Association of Insurance Commissioners (NAIC) in response to the global financial crisis.
One, called the Holding Company Act, enhances our ability to oversee, monitor and regulate any company under a parent company or holding company system. It must be adopted by Jan. 1, 2016, or Washington state risks losing its NAIC accreditation. This model act aims to improve transparency and accountability of companies and conglomerates that own insurance companies. The legislation would also prevent firms from circumventing regulation designed to protect against financial shell games that could result in insolvency.
The other is called the Own Risk and Solvency Assessment (ORSA) Model Act and requires companies to create a plan for self-assessing and reporting their current and future financials in light of their two- to five-year business plans.
Alien Insurer State of Entry (HB 1402/SB 5489)
This bill modernizes the terms under which international insurance companies could enter the U.S. insurance market through Washington state and requires them to meet the same financial-strength standards and play by the same rules.
K-12 Data Study Funding Restoration
The Legislature passed SB 5940 in 2012, requiring our office to annually study and report on K-12 employee benefits. The original bill included an appropriation of $1.3 million, but the funding was cut last year to $300,000. Without restored funding, we cannot complete the study. This bill restores the funding to its original appropriation.
We post this information on our legislative priorities page.
Public comment on bills
The state Legislature’s website has a new feature that allows citizens to comment on bills. All comments are emailed to all state legislators. If you are interested in commenting on these bills or any others that are being considered, you can search for the bill and select “comment on this bill” next to the bill number.
Over the cliff? [UPDATED]
[Please scroll down for update - HGS]
We've maintained for a long time that the actual intended result of the ObamaTax was, in fact, Single Payer. And the evidence making that case continues to pile up:
"Aetna CEO Mark Bertolini told CNBC on Wednesday that Obamacare has failed to attract the uninsured, and he offered a scenario in which the insurance company could be forced to pull out of program ... He said that so far, Obamacare has just shifted people who were insured in the individual market to the public exchanges where they could get a better deal on a subsidy for coverage"
Let's unpack this a bit, shall we?
First, I think it is rather frightening - and instructive - that the CEO of a publicly traded company, let alone a major player in the health insurance market, is signaling that his company may willingly walk away from its individual policy market. That represents a major portion of its core business, and he's saying that it may well go "poof."
Second, the news - and most of our readers already know this, of course - that the majority of the "new" business coming into the Exchanges is, in fact, folks whose previous coverage was cancelled despite the President's explicit and repeated promise that this would not happen. So we're not talking about "newly" insured here. As Yogi Berra, CLU might opine, "the uninsured are staying away in droves."
Not exactly what we were promised, either.
UPDATE: In the comments, John F and Bob H make the point that this may be much ado about, well, nothing much. Upon reflection, I think I have to agree with them. On the other hand, it's probably worth at least noting that Aetna is signalling their concern over the viability of the individual market. Is this concern over-stated? Perhaps. It will be, um, interesting to see how this plays out.
We've maintained for a long time that the actual intended result of the ObamaTax was, in fact, Single Payer. And the evidence making that case continues to pile up:
"Aetna CEO Mark Bertolini told CNBC on Wednesday that Obamacare has failed to attract the uninsured, and he offered a scenario in which the insurance company could be forced to pull out of program ... He said that so far, Obamacare has just shifted people who were insured in the individual market to the public exchanges where they could get a better deal on a subsidy for coverage"
Let's unpack this a bit, shall we?
First, I think it is rather frightening - and instructive - that the CEO of a publicly traded company, let alone a major player in the health insurance market, is signaling that his company may willingly walk away from its individual policy market. That represents a major portion of its core business, and he's saying that it may well go "poof."
Second, the news - and most of our readers already know this, of course - that the majority of the "new" business coming into the Exchanges is, in fact, folks whose previous coverage was cancelled despite the President's explicit and repeated promise that this would not happen. So we're not talking about "newly" insured here. As Yogi Berra, CLU might opine, "the uninsured are staying away in droves."
Not exactly what we were promised, either.
UPDATE: In the comments, John F and Bob H make the point that this may be much ado about, well, nothing much. Upon reflection, I think I have to agree with them. On the other hand, it's probably worth at least noting that Aetna is signalling their concern over the viability of the individual market. Is this concern over-stated? Perhaps. It will be, um, interesting to see how this plays out.
Insurance News - Thursday, January 24, 2013
Here are the leading auto insurance headlines from ONTARIO AUTO INSURANCE TOPICS ON TWITTER for Thursday, January 24, 2013:
- Kanetix study shows Ontario auto insurance rates for Q4 2012 were 3.3% lower compared to Q4 2011 (FSCO indicates a 0.26% decline).
- 36 percent of New York City no-fault auto insurance claims in 2010 had some element of fraud.
- Missouri man has 2 vehicles stolen on same day - in case you're wondering only 1 had the keys in the ignition.
- IBC study shows insurers are key contributors to Ontario's economic success.
- Low interest rates put upward pressure on P&C insurance premiums and solvency risk according to Standard & Poor.
Insurance News - Friday, January 24, 2014
Here are the leading auto insurance headlines from ONTARIO AUTO INSURANCE TOPICS ON TWITTER for Friday, January 24, 2014:
- Will insurers begin to use social media posts (eg., Facebook) to evaluate risky lifestyles when calculating premiums?
- Car theft victims are also using social media to track down stolen cars.
- Last year, more Torontonians were killed by cars (63) than by homicide (56). So why aren't we doing anything about it?
- Crash test indicate that tiny vehicles have major safety disadvantages. Only the Chevrolet Spark had acceptable test ratings.
- FSCO is in the process of launching their Arbitration eCalendar, which is expected to will streamline the arbitration booking process.
It's a Green Thing
What with all the winter white covering the ground, it's easy to forget that there's green underneath, as well. FoIB Bob Graboyes, senior research fellow at the Mercatus Center at George Mason University, has a slightly different take on the color, though:
"The battle for the soul of American health care is not really one of Democrat versus Republican or liberal versus conservative. Rather, it is between competing visions we can call the Fortress and the Frontier."
And what, you may ask, is "the Frontier?"
Well, as Bob explains it:
"The Frontier believes elites overestimate the capabilities of insiders and underestimate the abilities of outsiders. Innovation is the imperative."
And he then explains exactly how innovation and lateral thinking can drive down health care costs while maximizing effectiveness.
And make sure to check out the green plastic fingers.
"The battle for the soul of American health care is not really one of Democrat versus Republican or liberal versus conservative. Rather, it is between competing visions we can call the Fortress and the Frontier."
And what, you may ask, is "the Frontier?"
Well, as Bob explains it:
"The Frontier believes elites overestimate the capabilities of insiders and underestimate the abilities of outsiders. Innovation is the imperative."
And he then explains exactly how innovation and lateral thinking can drive down health care costs while maximizing effectiveness.
And make sure to check out the green plastic fingers.
Friday, January 23, 2015
Two insurers fined $250,000
A California insurer and its sister company are being fined $250,000 for multiple violations of Washington’s insurance laws.
Health Net Health Plan of Oregon, Inc. and Health Net Life Insurance Co., of Woodland Hills, Calif., have signed a consent order jointly agreeing to pay the fine.
The violations include:
• As an illegal inducement to keep customers, the companies offered an unapproved premium holiday – a month of free insurance -- to hundreds of customers. (State law says that insurers must use the rates they file with state regulators.)
• Customers were transferred to new plans with a different company, but were wrongly told that the change was simply a “renewal” of the policy.
• By not telling customers that they had been transferred to a different company, the companies also violated a state law requiring insurers to use their own names.
“I’m all for consumers getting a break on their health insurance premiums,” said Insurance Commissioner Mike Kreidler. “But insurers have to follow the same rules their competitors do. If they say they’re going to charge a particular rate, that’s the rate they should use.”
Health Net Health Plan of Oregon, Inc. and Health Net Life Insurance Co., of Woodland Hills, Calif., have signed a consent order jointly agreeing to pay the fine.
The violations include:
• As an illegal inducement to keep customers, the companies offered an unapproved premium holiday – a month of free insurance -- to hundreds of customers. (State law says that insurers must use the rates they file with state regulators.)
• Customers were transferred to new plans with a different company, but were wrongly told that the change was simply a “renewal” of the policy.
• By not telling customers that they had been transferred to a different company, the companies also violated a state law requiring insurers to use their own names.
“I’m all for consumers getting a break on their health insurance premiums,” said Insurance Commissioner Mike Kreidler. “But insurers have to follow the same rules their competitors do. If they say they’re going to charge a particular rate, that’s the rate they should use.”
Insurance News - Wednesday, January 23, 2013
Here are the leading auto insurance headlines from ONTARIO AUTO INSURANCE TOPICS ON TWITTER for Wednesday, January 23, 2013:
- The 2010 Ontario auto reforms has produced a shift from statutory accident benefits to tort.
- A recent FSCO arbitration decision only reinforces it's time to replace the Glasgow Coma Scale when determining catastrophic impairment.
- Bizarre auto accident: Woman killed by runaway truck at a car wash.
- National Insurance Crime Bureau (NICB) has released a report that examines the impact that organized crime groups have on insurance fraud.
- Ontario's projected 2015-13 deficit falls by $3 billion to $11.9 billion due to higher than expected revenues and lower expenses. Minister Duncan indicates corporate taxes up over $1 billion and there will $1.2 billion saved because of lower interest payments on debt and reduced banked sick days for teachers.
What Impact The Proposed Anti-Fraud Regulatory Amendments Have?
As previously mentioned the Ontario government plans to introduce new regulatory amendments as part of its anti-fraud initiative. These amendments are just some of the recommendations made by the Anti-Fraud Task Force. Here is a brief description of those proposed amendments and how they will impact on the auto insurance system.
Requiring insurers to provide claimants all reasons for denying a claim
Currently subsections 36(4)(b), 36(7)(b), 37(4), 37(6)(c), 38(8), 38(14)(a), 38(14)(b), 42(3), 42(13)(b), 43(2), 44(5)(a), 45(3)(b) and 45(5)(b) of the SABS require insurers to provide claimants with "medical and any other reasons" for denying a claim for accident benefits. These subsections were amended in September 2010 to specifically provide a full explanation to claimant for denials. The Anti-Fraud Task Force heard from stakeholders that adjuster were not providing an a proper explanation and often just indicated that the claim was "not reasonable and necessary." It will be interesting to see what language the government comes up with to motivate adjusters to change their behaviour. There is also an enforcement aspect that will be needed to have an impact.
Giving claimants the right to receive a bi-monthly, detailed statement of benefits paid out on their behalf
In September 2010, the new SABS introduced by the government included section 50 which requires insurers to provide a bi-monthly benefit statement to claimants indicating the amount paid by the insurer on behalf of the claimants for medical, rehabilitation and attendant care benefits as well as the amount spent on insurer examinations. The statement also required to inform the claimant the amount of benefits still remaining. The experience has been that insurers have been providing these statements but with no more detail than required under the SABS. The statements do not breakdown payments by provider or service. Consequently, consumers are unable to determine whether the payments made on their behalf are legitimate. The government plans to amend section 50 to require the insurer to provide more detail. The amount of detail is not known publicly at this time.
Increasing the role of claimants in fraud prevention
This involves adding two new provisions to the SABS. The first would require claimants to confirm attendance at treatment facilities. The second would require facilities to provide a copy of invoices for goods and services billed to insurers. These proposed provisions expand on an amendment made to the SABS in June 2011. Section 46.2 was added to the SABS to require facilities to provide an insurer with information to support any invoice for goods and services billed to that insurer. These amendments would require facilities to copy claimants on invoices and for claimants to confirm that they received those goods and services.
Making providers subject to sanctions for overcharging insurers for goods and services and banning them from asking consumers to sign blank claim forms
The government press release is rather sketchy but the Ontario government Regulatory Register is more specific on the proposed changes. First there would be an amendment to Reg. 283/95 to provide insurers with the ability to examine a claimant under oath, where this is necessary to determine which insurer should be responsible for coverage. This would be in addition to the right for an examination under oath that now exists under section 33 of the SABS. The SABS requirement is limited to matters related to entitlement to benefits. The SABS provision is an anti-fraud measure but currently insurers sometimes use it to determine liability and therefore no longer have access to an examination under oath to determine entitlement. A new provision in Reg. 283/95 will resolve that problem.
The government will also amend Reg. 7/00 to expand business practices that would be considered an unfair or deceptive acts or practice. In the future it will include when providers charge insurers much more for goods or services than the ordinary retail price. This provision is currently covered by a Superintendent's Guideline. A further amendment will ban the practice of having claimants sign blank claim forms.
Lastly the government has signalled that it will also amend Reg. 7/00 to clarify the exemption for lawyers and paralegals in the unfair or deceptive acts or practices regulation applies to lawyers and paralegals only when they are acting in a legal capacity. This means that lawyers will continue to be regulated by the Law Society of Upper Canada when they act in a legal capacity. However, if a lawyer is an owner of a clinic and not acting in a legal capacity, then any business practice that is in contravention of the Insurance Act would be subject to regulatory action by FSCO.
Requiring insurers to provide claimants all reasons for denying a claim
Currently subsections 36(4)(b), 36(7)(b), 37(4), 37(6)(c), 38(8), 38(14)(a), 38(14)(b), 42(3), 42(13)(b), 43(2), 44(5)(a), 45(3)(b) and 45(5)(b) of the SABS require insurers to provide claimants with "medical and any other reasons" for denying a claim for accident benefits. These subsections were amended in September 2010 to specifically provide a full explanation to claimant for denials. The Anti-Fraud Task Force heard from stakeholders that adjuster were not providing an a proper explanation and often just indicated that the claim was "not reasonable and necessary." It will be interesting to see what language the government comes up with to motivate adjusters to change their behaviour. There is also an enforcement aspect that will be needed to have an impact.
Giving claimants the right to receive a bi-monthly, detailed statement of benefits paid out on their behalf
In September 2010, the new SABS introduced by the government included section 50 which requires insurers to provide a bi-monthly benefit statement to claimants indicating the amount paid by the insurer on behalf of the claimants for medical, rehabilitation and attendant care benefits as well as the amount spent on insurer examinations. The statement also required to inform the claimant the amount of benefits still remaining. The experience has been that insurers have been providing these statements but with no more detail than required under the SABS. The statements do not breakdown payments by provider or service. Consequently, consumers are unable to determine whether the payments made on their behalf are legitimate. The government plans to amend section 50 to require the insurer to provide more detail. The amount of detail is not known publicly at this time.
Increasing the role of claimants in fraud prevention
This involves adding two new provisions to the SABS. The first would require claimants to confirm attendance at treatment facilities. The second would require facilities to provide a copy of invoices for goods and services billed to insurers. These proposed provisions expand on an amendment made to the SABS in June 2011. Section 46.2 was added to the SABS to require facilities to provide an insurer with information to support any invoice for goods and services billed to that insurer. These amendments would require facilities to copy claimants on invoices and for claimants to confirm that they received those goods and services.
Making providers subject to sanctions for overcharging insurers for goods and services and banning them from asking consumers to sign blank claim forms
The government press release is rather sketchy but the Ontario government Regulatory Register is more specific on the proposed changes. First there would be an amendment to Reg. 283/95 to provide insurers with the ability to examine a claimant under oath, where this is necessary to determine which insurer should be responsible for coverage. This would be in addition to the right for an examination under oath that now exists under section 33 of the SABS. The SABS requirement is limited to matters related to entitlement to benefits. The SABS provision is an anti-fraud measure but currently insurers sometimes use it to determine liability and therefore no longer have access to an examination under oath to determine entitlement. A new provision in Reg. 283/95 will resolve that problem.
The government will also amend Reg. 7/00 to expand business practices that would be considered an unfair or deceptive acts or practice. In the future it will include when providers charge insurers much more for goods or services than the ordinary retail price. This provision is currently covered by a Superintendent's Guideline. A further amendment will ban the practice of having claimants sign blank claim forms.
Lastly the government has signalled that it will also amend Reg. 7/00 to clarify the exemption for lawyers and paralegals in the unfair or deceptive acts or practices regulation applies to lawyers and paralegals only when they are acting in a legal capacity. This means that lawyers will continue to be regulated by the Law Society of Upper Canada when they act in a legal capacity. However, if a lawyer is an owner of a clinic and not acting in a legal capacity, then any business practice that is in contravention of the Insurance Act would be subject to regulatory action by FSCO.