We received a favorable decision in an Aetna disability case today, where the Court found that Aetna's denial was unreasonable and that it ignored the evidence in its own files: "It is puzzling that Aetna’s explanation for its denial in the letter sent to Plaintiff states that neither Dr. Wang nor Dr. Mehta provided “submitted any clinical rationale or any resent [sic] test results,” when both doctors included test results, including the recent MRI results, and all of Plaintiff’s medical records in faxes submitted to Aetna in support of their clinical assessments finding Plaintiff permanently disabled."
Here is an article that I wrote some time ago about when an insurance company must defend its insured when the insured is facing a lawsuit.
WestLaw has published another recent case of mine, Carrier v. Aetna Life Insurance Co., 116 F. Supp. 3d 1067 (C.D. Cal. 2015). Judge O'Connell ruled that the insured was disabled under the terms of her group disability insurance plan. In the denial letter, Aetna told Ms. Carrier that her file had been reviewed by a psychiatrist who stated that she was not disabled when in fact Aetna never hired a psychiatrist prior to the denial.
WestLaw has published a recent case of mine, Williby v. Aetna Life Insurance Company, 2015 WL 5145499 (C.D. Cal. Aug. 31, 2015). Judge Consuelo Marshall ruled that the insured was disabled under the terms of her group disability insurance plan and that even though the benefits were self-funded, California Insurance Code § 10110.6 voided the plan's effort to make the abuse of discretion standard apply.
Here's an article published this month that I wrote regarding things to watch out for in group life, health, and disability cases. They are subject to the Employee Retirement and Income Security Act "ERISA."
Accident policies provide coverage in the event of accidental death, dismemberment, and other specified injuries. These policies are divided into two categories: "accidental death" policies and "accidental means" policies. "Accidental death" policies have very broad coverage and insure for essentially any death that is not expected or intended by the insured. Here is an article that I wrote on the subject.
If due to a sickness or accident you are unable to work, you may be entitled to something called "disability" benefits. You don't need to be disabled in the traditional sense to recover. You just have to be unable to perform the substantial and material duties of your normal occupation in the usual and customary way. If you become disabled, make sure to submit your claim right away. Below is a list of the different kinds of benefits to which you might be entitled:
Group Disability Coverage
Many people have disability insurance through their employer. You will need to check with your human resources department. Benefits are usually divided into short-term disability benefits ("STD") and long-term disability benefits ("LTD"). If your claim is denied, we can help.
Individual Disability Coverage
Some people purchase their own individual disability insurance through an agent or directly from a disability insurance company. If you are self-employed or want coverage in addition to that provided by your employer, an individual policy will protect you if you are no longer able to work. If your claim is denied, we can help.
If you are injured on the job, you are entitled to payments through the workers compensation system. We do not handle these types of cases, but we can refer you to a specialist.
California State Disability
The State of California will pay disability benefits for the first year of disability, sometimes called EDD or SDI benefits. They are ordinarily very good about paying such claims.
Social Security Disability
The Social Security Administration will also pay you disability benefits if you cannot work. You do not have to be 65 or older to qualify. These benefits are not related to retirement. You can submit a claim through any Social Security office. Initial claims are sometimes denied, requiring an appeal. We do not handle these types of cases, but we can refer you to a specialist.
Here is an article that I wrote for the Advocate on loss of rents coverage. For people that own buildings that they rent out, many policies will provide coverage for loss of rental income even if the building is not rented to a tenant when a loss occurs to the building such as a fire, burst water pipe, or vandalism.
When it comes to health insurance, most people understand that if they have a deductible, they are probably going to have to pay that amount first before their health insurer starts to pay anything. After that, co-payments apply. Most plans require the insured or plan participant to pay 10% to 30% of the cost of the care after the deductible is met. Some plans, of course, have a $0 deductible, so co-payments apply at the start.
What most people do not realize, however, is that there is something called an Annual Out-of-Pocket Maximum in every health insurance policy and plan regardless of whether it is an HMO, PPO, or EPO. This number is way more important than the deductible or co-payment amount because it puts a cap on the amount that the insured has to pay. There used to also be a cap on the amount that the insurance company had to pay, but those caps known as the lifetime maximum have been removed by the Affordable Care Act. Previously, most health insurance policies had a $1 million or $3 million lifetime limit. This limit very rarely came into play and was really more of a marketing gimmick.
The Annual Out-of-Pocket Maximum is vitally important for consumers, though, because it puts a cap on the amount that you have to pay for health care each calendar year. Once you pay the amount stated in the policy or plan for the Annual Out-of-Pocket Maximum, the insurance company is required to pay 100% of covered medical expenses for the remainder of the year.
So, when shopping for health insurance if you are buying your own policy, one of the most important things to look for is the amount of the Annual Out-of-Pocket Maximum.