When an insurance company receives a claim from its policyholder, the first thing the adjuster does is “check coverage.” This means they verify the policy is in force by making sure the premiums have been paid and the policy period is in effect. Then, the adjuster looks at the facts of the claim the policyholder
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Claim Handlers’ “Say No First, Ask Questions Later” Attitudes Can be Costly
There are many people working as claims professionals in the insurance business who strive to do the right thing by the company’s policyholders. When I run into one of them, it is like a breath of fresh air. These folks seem to genuinely care about policyholders and work hard to try to find ways to pay claims. They
Does Using Biased Experts Violate the Duty of Good Faith?
Insurance companies often hire an “expert” as part of their investigation of a policyholder’s claim. The expert can be a doctor, an engineer, an accident reconstructionist, an accountant, etc. , depending on the type of claim and the issue being investigated. Insurance companies and their lawyers love nothing better than to claim that because they
Health Insurance Company Denying Coverage for ER Visits it Deems Unnecessary After the Fact
In an excellent recent article in the New York Times, a claim-handling practice by Anthem Blue Cross Blue Shield was brought into the public light. Anthem has begun denying its policyholders’ claims for coverage for emergency room visits if Anthem determines after the fact that the policyholder didn’t really need to go to the emergency
UnitedHealth’s Profit Motive Collides with its Policyholder’s Health
CNN’s Wayne Drash (@drashmanCNN) has written a series of gut-wrenching, infuriating and telling stories recently regarding the health insurance industry’s treatment of policyholders. They illustrate how profit is a more powerful motivator to the health insurance industry that policyholders. Anyone interested in this issue specifically or responsible corporate behavior in general should take a look
Health Insurance Company Doctors are Often Unqualifed
When you make a health insurance claim, oftentimes your health insurance company will have a doctor employed by the company review the claim to see if it should be paid. The problem I have seen in a number of cases is the doctors reviewing policyholders’ claims are horribly unqualified to make fair decisions on those
Health Insurance – When Does the Duty of Good Faith Apply?
Because the health insurance industry has legal immunity in many situations from bad faith lawsuits, it operates differently in many ways than the remainder of the insurance industry. Health insurance companies do not tend to investigate and evaluate claims in the same manner as auto insurance or homeowners insurance companies. My experience prosecuting bad faith lawsuits against
Aetna Under Investigation in California for Health Insurance Claim Handling Practices
CNN just ran an incredible story by Wayne Drash (see it here) on a health insurance claim denial by one of the country’s largest insurers, Aetna. The story involved the case of Gillen Washington, a 23-year-old Californian, who is represented by attorney Scott Glovsky. Apparently, Aetna denied medical treatment to Gillen based on the
How Do Insurance Companies Track “Quality” Claim Handling?
“Quality Assurance” or “QA” is a familiar concept in lots of industries (like manufacturing for example), and the insurance industry has widely implemented QA operations in their business as well. Insurance companies say they want their adjusters to handle policyholders’ claims in a “quality” fashion. To be sure adjusters are doing so, insurance companies use
Profit-Making Culture in Insurance Claim Departments
As discussed in previous posts, an insurance company violates the duty of good faith and fair dealing when it attempts to alter the terms of its policy bargain with the policyholder by attempting to use its claim department as a profit center.
How does an insurance company get its claim personnel to buy in to