Jon Michael Smith, AttorneyInsurance Lawyer-Plaintiff | Jon Michael Smith | Austin2024-03-12T18:56:33Zhttps://www.jonmichaelsmith.com/feed/atom/WordPressOn Behalf of Jon Michael Smithhttps://www.jonmichaelsmith.com/?p=503092024-03-12T18:56:33Z2024-03-12T18:56:33Zdelays, underpays or denies benefits, a patient in a health crisis can face medical bills running into seven figures.
To pay for necessary treatment, a Texan may have to face bankruptcy or the prospect of trying to raise the funds by asking for help or raiding one’s retirement assets.
Like other insurance companies, health insurance carriers must follow the terms of their policy as well as all Texas and federal laws. They may not delay or deny benefits in bad faith.
What is or is not bad faith will depend a lot on a person’s circumstances and the language of the insurance policy. Some examples of bad faith include automatically denying a claim for benefits without investigating and requiring extra, unnecessary paperwork to get benefits.
If a health insurance carrier acts in bad faith, then the patient needing the benefits may have legal options under Texas law.
They may be able both to compel the insurance company to pay and obtain additional compensation from the insurance company for the trouble.
Employer health insurance claims may be subject to ERISA
Many people have health insurance through their employer’s plans. Like retirement and employer-sponsored disability plans, employer health insurance plans are subject to ERISA. ERISA is a federal law designed to give workers assurance that they will get the benefits their employer promises.
The provisions for ERISA may provide additional protections for workers. On the other hand, some ERISA requirements may supplement or even contradict Texas law.
For example, under ERISA, workers are expected to try administrative appeals before suing their insurance companies for bad faith.
Handling a health insurance dispute under ERISA can be a complex matter. Texans facing this situation will want to make sure they understand their legal options.]]>0On Behalf of Jon Michael Smithhttps://www.jonmichaelsmith.com/?p=503072024-02-28T15:52:32Z2024-02-28T15:52:32Z8% of motorists are operating without legally required automobile liability insurance. Putting that in perspective, that’s slightly fewer than 1 out of every 10 cars an Austin resident might see on the road.
This figure does not tell the whole story. For one, some estimate the number of uninsured motorists in Texas to be much higher than the Institute.
Furthermore, Texas only requires drivers to have liability insurance that will pay individual accident victims up to $30,000. If there are multiple victims, the minimum coverage would only pay $60,000 total.
While this minimal amount keeps drivers legal in our state, most people can probably see that any serious accident could cost an innocent motor vehicle accident victim far more than $30,000 in medical bills alone, not even considering lost wages, non-economic losses and other damages.
An injured victim may have to turn to their own insurance carrier
Texans have the option to buy uninsured and underinsured motorist coverage from their own automobile insurance carriers.
If they did buy this coverage, accident victims should turn to their own insurance carriers for additional compensation if an uninsured motorist is responsible for their injuries.
They may also file a claim with their own carrier if a negligent driver’s limits are not enough to fully compensate them.
Even dealing with one’s own insurance company can be complicated and frustrating. Victims needing to file a claim for uninsured and underinsured benefits should make sure they understand their legal options. They will need to know how to deal with their insurance company effectively.]]>0On Behalf of Jon Michael Smithhttps://www.jonmichaelsmith.com/?p=503012024-02-12T17:07:26Z2024-02-14T17:06:30ZDelayed and denied claims
Unfortunately, delayed or denied claims are quite frequent in Texas and throughout the country, under almost any type of insurance policy that a person or business might have. When delayed or denied claims happen, this can lead to time-consuming – and oftentimes aggravating – back-and-forth discussions with the insurance company to attempt to get the claim payout moving.
But, fortunately, Texas has an insurance code law that protects consumers from insurance companies that may not be acting in the consumer’s best interests. Sometimes, there are allegations of “bad faith” or other missteps that the insurance company might engage in. And, of course, any insurance policy is actually written by the insurance company – meaning that the terms of this “contract” are hardly ever favorable to the consumer.
If you are experiencing a delayed or denied claim with your insurance company, it may be time to look to Texas’ insurance code for help. It may even take litigation to get your insurance company to pay out your claim in the end.]]>0On Behalf of Jon Michael Smithhttps://www.jonmichaelsmith.com/?p=502982024-01-31T20:48:01Z2024-02-06T19:18:10Z16 disasters in which the cost was $1 billion or more. This was highest number of billion-dollar disasters the state has ever recorded.
Climate scientists say the frequency and intensity of these disasters are increasing. This subject matter is controversial in some circles, but it's important to know that there is one sector that takes it very seriously, and that sector is the insurance industry.
Insurers are preparing for future disasters by raising rates on homeowners insurance. Texas, rates went up last year by an average of 22%, about twice the national average. Still, some areas were hit even worse. In some parts of the country, homeowners are finding it increasingly difficult to find insurance for their homes at any price.
The rate hikes tend to be concentrated in coastal areas, but the costs are going up almost everywhere.
If you can't get insurance
This situation puts millions of ordinary homeowners in a bind. Technically, it may be possible to own a home without insurance, but mortgage lenders typically require the homeowner to carry insurance. And of course, the cost to the homeowner of repairing an uninsured home after a fire or other disaster can be prohibitive.
There are some options to help.
Homeowners who have been turned down by at least two insurance companies may seek out coverage under the Texas FAIR Plan Association. Depending on their circumstances, they may have other options as well.
Protecting yourself if you have insurance
Even if you do have insurance, it's important to be careful with it. Remember that your insurance company is looking for ways to keep its costs down, and that means it has a motive to deny your claim or to give you less than your claim deserves.
Some things you can do to protect yourself:
Document damage and keep receipts
Contact your insurer as early as you can after any damage. If your home requires immediate attention, make only temporary repairs until your insurer inspects the damage.
Be sure to be present when the insurance company inspects the damage and make sure your agent has a good way to contact you.
If you are denied a claim unfairly, you may need to take legal action.]]>0On Behalf of Jon Michael Smithhttps://www.jonmichaelsmith.com/?p=502952024-01-30T18:50:10Z2024-01-30T18:50:10ZTexas Prompt Payment of Claims Act
The Texas Prompt Payment of Claims Act serves as a regulatory framework governing how homeowners’ insurance companies manage claims in the state. The TPPCA meticulously outlines deadlines for insurance companies regarding the acknowledgment, investigation, acceptance, rejection or payment of claims. Additionally, penalties are imposed for non-compliance.
Deadlines
Per the TPPCA, an insurance company must adhere to the following timelines upon receiving a claim. First, the homeowners’ insurance company must acknowledge the claim’s receipt within 15 days. It must then initiate an investigation within 15 days, and request any necessary additional information within 15 days.
It must convey acceptance or rejection in writing within 15 business days post-receiving all required information. The homeowners’ insurance company must complete the payment within five business days post-acceptance.
What about extensions?
Extensions to these deadlines may be granted under specific circumstances. These extensions include weather-related catastrophes, and of course, the policyholder can request extensions. However, the insurer is obligated to inform the policyholder of any extensions and their reasons.
Penalties for TPPCA violations
Failure to comply with TPPCA deadlines exposes an insurance company to additional damages, interest and attorney’s fees. Policyholders can pursue legal action against their insurer for breach of contract and bad faith under the TPPCA.
The TPPCA imposes an 18% per annum interest penalty on the owed claim amount from the due date until payment. In addition, prevailing policyholders in a lawsuit against their insurance company can recover reasonable attorney’s fees.
Safeguarding your rights as a policyholder
Homeowners in Austin, Texas, navigating insurance claims should understand and assert their rights under the TPPCA. To safeguard these rights and ensure fair and timely claim handling, homeowners can take specific measures.
Maintain detailed records of all interactions with the insurance company, including calls, emails, letters and texts. Thoroughly document property damage with photos, videos, receipts, invoices, estimates and repair bills.
Cooperate with the insurance adjuster, providing requested information or documents. But, scrutinize the insurance policy to comprehend coverage and exclusions. And, refrain from accepting inadequate settlement offers or signing documents that waive rights.]]>0On Behalf of Jon Michael Smithhttps://www.jonmichaelsmith.com/?p=502902024-01-17T16:47:41Z2024-01-17T16:47:41Ztheir rights under ERISA.
This aspect of the law, which falls under Section 510 of the act, is sometimes known as ERISA's anti-retaliation provision.
What counts as retaliation?
Retaliation is a common element of claims in employment law, but its definition can be somewhat vague. Many worker protection laws, including ERISA, contain a provision that prohibits employers from taking any adverse action against an employee simply because they have exercised a protected right.
For example, let's say an employee exercises her right to use her health benefits when she has serious health problems and requires expensive medical benefits. Indeed the costs are so high that it drives up the cost of premiums for the employer's health plan. This angers her boss so much he fires her. The worker then sues the employer for wrongful termination and retaliation. In this case, a court would almost certainly find that the employer committed unlawful retaliation because it fired the employee simply because she exercised her right under ERISA.
Now, let's remember that we said employers cannot take "any adverse action" against an employee simply because they exercised their rights under the law. This means these individuals are protected from not just termination but also many other actions that would negatively affect the employee's status, such as demoting them, reducing their pay, denying them a promotion, transferring them to a less-desirable position, reducing their hours or more.
ERISA is a complex law, and it can apply to a wide range of issues in employment. A worker who has had trouble after using heath or retirement benefits may wish to speak to an experienced professional to learn more about how the anti-retaliation provision might apply to their case.]]>0On Behalf of Jon Michael Smithhttps://www.jonmichaelsmith.com/?p=502852024-01-17T11:24:22Z2024-01-17T11:24:22ZWhat if I disagree with the insurance adjuster’s calculation?
There are ways to combat what a policyholder believes is an unfair estimate. First, it is important to inform the company about the gap between the adjuster and what the policyholder believes should be paid. It is possible that it was just an oversight and can be rectified relatively easily.
If the company stands by its claim, the policyholder can ask for an appraisal. The company and policyholder will each hire a professional to appraise the damaged or destroyed property. A third appraiser will look at each estimate and make an objective determination. It is binding, so people should be cognizant of that. Each side must pay half for the independent appraiser’s services.
When the policyholder is still displeased with the result, filing a complaint with the Texas Department of Insurance is the next step. Since it is a regulatory agency, it holds sway with adjusters it oversees. This could be useful if the adjuster is being unreasonable in the policyholder’s view. If there is a legal violation, TDI can also help.
Having professional advice may be useful
Insurance claims can be complex and people are frequently focused on getting approved and receiving some level of compensation for what was lost. Another area of disagreement is the value of what was lost and how much it costs to replace or repair. For these circumstances, it is just as important to know what can be done to reach a fair resolution.
]]>0On Behalf of Jon Michael Smithhttps://www.jonmichaelsmith.com/?p=502832024-01-04T20:02:37Z2024-01-03T20:01:30ZLife insurance overview
A life insurance policy is purchased by an individual who is usually required to provide information about their health and lifestyle. If they meet the insurance company’s criteria for coverage, it will offer them a policy and state how much the policyholder will pay in premiums each month.
Once the policyholder passes away, the beneficiaries can file a claim for payment. The life insurance company can deny payment for several reasons, including that the policyholder misrepresented information on the application, for non-payment of premiums which caused the policy to lapse, and failure to disclose pre-existing medical conditions that contributed to the policyholder’s death.
It may also be denied if the life insurance company states there was policy fraud, such as submitting false documents or if the policyholder’s cause of death is specifically excluded from the policy.
Appeals
If the claim is denied, the beneficiaries can appeal. First, they will want to review the denial letter from the insurance company. It may be necessary to provide additional documentation, such as medical records or the death certificate.
The beneficiaries can submit a written appeal and should be prepared to demonstrate how the claim meets the coverage in the policy. If the appeal with the insurance company is not successful, it may be necessary to resolve the issue in court.]]>0On Behalf of Jon Michael Smithhttps://www.jonmichaelsmith.com/?p=502792023-12-27T19:31:15Z2023-12-19T19:29:08ZAn appeal
Some insurance companies have internal appeal processes incorporated into the text of the insurance contract, and this process must be followed before any external appeal may be filed. Most policies do not contain such a provision, and the policy holder’s only option is a lawsuit challenging the legal validity of the insurer’s denial. Before pursuing a court appeal, the policy holder should do several things.
The first is understanding exactly what the company has done and why. The denial letter must clearly state the reasons for the denial of the claim. Some healthcare policies, for example, require a referral for care rendered by a physician who is not part of the insurance company’s network of care givers.
If this information is not contained in the denial letter, an inquiry from a lawyer experienced in insurance coverage may convince the insurer to provide the requested information. The policy may state a deadline for filing a court appeal. Do not let this deadline pass without taking action.
Gathering documents
Many insurance claims rely on documentary evidence to prove the basis for the claim. This is especially true for claims under health insurance policies and business interruption claims.]]>0On Behalf of Jon Michael Smithhttps://www.jonmichaelsmith.com/?p=502772023-12-07T05:53:31Z2023-12-07T05:53:31ZWhat is ERISA?
ERISA is the federal law regulates employee benefit plans. Benefit plans include health, disability and life insurance, along with pension plans, among many other types of employee benefit plans. ERISA sets the floor, or the minimum standards for such plans, like the disclosure and reporting requirements, along with the fiduciary responsibilities and enforcement mechanisms.
Are ERISA claims treated differently in Texas?
To be clear, ERISA overrides most Texas laws that relate to employee benefit plans. However, it does not cover all employee benefit plans because some plans are exempt from ERISA. These exempt plans include governmental plans, church plans and those employee benefit plans that exist solely for legal compliance with workers’ compensation, unemployment or disability laws. ERISA also does not apply to any employee benefit plan that is not established or maintained by an employer or employee organization.
What does that mean?
It means that if your employee benefit plan is covered by ERISA, and you are denied benefits, you will need to file an ERISA claim. However, if not, you may be able to sue under Texas law for wrongful denial of benefits, bad faith, negligence or breach of contract. This is an important distinction because none of those claims are available under ERISA.
ERISA also does not allow for punitive damages, emotional distress damages or provide a jury trial right for most claims. This means that your case will be decided by a judge, not by a jury of your peers, in most cases.
ERISA does not allow you to introduce new evidence in court that was not presented during the administrative process. And, ERISA gives deference to the plan administrator’s decision, if the plan grants discretionary authority to the plan administrator. This means that the court will uphold the plan administrator’s decision unless it is arbitrary and capricious, an abuse of discretion or contrary to law.
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