Recently in Insurance Category

The California Restaurant Mutual Benefit Corporation (CRMBC) announced today its 4th conviction for Workers' Compensation fraud against an employer member.  Tamisha Carson pleaded no contest today in Solano County court to one count of insurance fraud, charged as a misdemeanor. Carson had been videoed in April 2008 staging an injury at a Vallejo Taco Bell.

Carson had claimed that a box of soda had fallen on her foot while she was attempting to move it.  Video surveillance reviewed by the Taco Bell franchisee, PRB Management, showed that she had in fact placed the box on her foot and called for help.  Intercare, the claims management company working with the CRMBC, denied the claim and launched its investigation through its Special Investigation Unit.  The case was pursued and conviction obtained by the Solano County District Attorney.

Carson will pay $1,255 in restitution as well as additional fines and fees and will be on probation for 2 years.  She will have 75 hours of community service and has been ordered to make at least 7 completed job applications per week and maintain full-time employment once she has a job.

Chair of the Board of Trustees for CRMBC, David Mitchell, said:

"We are stepping up our fight against Work Comp fraud in California.  Small employers are the backbone of our economy but they often don't get a lot of help.  CRMBC is going to continue to drive support to its members for safer workplaces, fewer injuries and an end to fraudulent claims."

SOURCE California Restaurant Mutual Benefit Corporation

California's Governor Schwarzenegger Bans Practice of Charging Women Higher Insurance Rates Than Men; Congressional Hearing Scheduled.

The National Women's Law Center's (NWLC) groundbreaking report "Nowhere to Turn: How the Individual Health Insurance Market Fails Women," first released in September 2008, brought to light how the insurance industry discriminates against women. Now, this ground-breaking research has resulted in the enactment of a law in California -- signed by Governor Schwarzenegger over the weekend -- that bans the insurance industry practice of gender rating or charging women more than men for the same services.

"For too long, gender rating has caused hardship to many thousands of women, who have either had to forgo health insurance altogether or sacrifice to cover the extra premium cost," said Marcia D. Greenberger, Co-President of NWLC.

NWLC is on the front lines in the fight to obtain meaningful health care reform that works for women and continues to develop new research and initiatives that will intensify the spotlight on unfair insurance industry practices. This Thursday, Ms. Greenberger is expected to testify on Capitol Hill about disparities in how insurance companies treat women.

Data and research from the NWLC report "Nowhere to Turn" has become the cornerstone of the argument used by women Senators, activists and other organizations who are advocating for meaningful health care reform. The report also highlights:

• Women are regularly denied coverage for "pre-existing conditions" including pregnancy, a previous C-Section or past domestic abuse
• Insurance companies charge women as much as 48% more for individual health care coverage than men
• It is expensive, difficult, and in some states impossible, for women to find coverage for maternity care when purchasing their own health insurance plan
• A state-by-state overview of how insurance practices adversely impact women
  

At the same time that the Governor signed the gender rating bill, he also vetoed a bill that would have required health plans to cover maternity services.

Greenberger stated: "Although he did not require coverage for maternity services, banning gender rating is a great first step for improving health care for women. However, piece-meal measures will not be enough. Health care reform must eliminate once and for all the many challenges that women face in getting access to quality, affordable, comprehensive health care."

SOURCE The National Women's Law Center

The notice process has begun in a pending class action against MetLife. The class action involves MetLife's April 2000 conversion from a mutual insurance company to a stock company. The nationwide class action certified by the Federal Court in New York includes more than 8.6 million current and former MetLife policyholders.

The notice of the class action will be mailed to more than 5 million current and former policyholders. The notice will also be published in two national newspapers. A more detailed notice is available at www.insuranceclassaction.net. Additional information is also at 800-961-8147.

The text of the mailed notice is set out below.

    ------------------------------------------------------------
    United States District Court
    Eastern District of New York

    In Re MetLife Demutualization Litigation
    00cv2258 (TCP) (AKT)

NOTICE OF CLASS ACTION

METROPOLITAN LIFE INSURANCE COMPANY ("MetLife Co.") POLICYHOLDERS WHO RECEIVED IN METLIFE CO.'S DEMUTUALIZATION AT LEAST (a) 11 TRUST INTERESTS OR (b) $156.75 IN CASH OR POLICY CREDITS.

YOU MAY BE A CLASS MEMBER IN THIS LAWSUIT AND YOUR RIGHTS COULD BE AFFECTED.

This notice describes (1) this class action lawsuit; (2) the class definition; (3) your right to share in any judgment or settlement, and the binding effect on you of any judgment or settlement if you do not exclude yourself from the class; (4) your right to be excluded from the class and how to exclude yourself; and (5) how to get more information.

This Lawsuit In April 2000, Metropolitan Life Insurance Company ("MetLife Co.") converted from a mutual insurance company to a stock company, called "demutualization." The suit is against MetLife Co. and MetLife, Inc. ("Defendants") by policyholders in the demutualization ("Plaintiffs"). Plaintiffs allege Defendants sent policyholders an information package that omitted material facts and contained false statements, to win the policyholders' vote to demutualize. Plaintiffs allege Defendants violated certain federal securities laws and damaged class members. Defendants deny plaintiffs' claims and are contesting the suit. Defendants believe they did not omit material information or make false statements to policyholders, and that class members were not damaged.

Class Members You received this notice because you may be a class member. In a class action, claims common to a group, called class members, are litigated together. The results bind all class members. Class members' rights will be affected by this lawsuit.

You are a class member if you received in MetLife Co.'s demutualization (a) 11 or more trust interests in MetLife, Inc. stock or (b) cash payment or policy credits of $156.75 or more.

Remaining a class member If you are a class member and do not exclude yourself (as described below), you will remain a class member. You will be represented by Lead Plaintiffs and Lead Counsel, Jared Stamell, Esq. You will share in any judgment and be bound by the Court's decisions, whether favorable or unfavorable. You will not be personally liable for attorneys' fees or other expenses. You may not bring your own suit for the same claims. (If you wish, you may be represented in this class action by your attorney at your own expense.)

Excluding yourself You can exclude yourself from the class. If you exclude yourself, you will not share in any judgment in the case or be bound by the Court's decisions, and may pursue your own claim against Defendants individually, at your own expense.

TO EXCLUDE YOURSELF, YOU MUST MAIL BY September 8, 2009 a signed, dated statement (with your name, the policy owner's name (if different from your name), policy number, your address and telephone number) saying you exclude yourself from the MetLife Demutualization Litigation to: MetLife Demutualization Litigation, Notice Administrator, c/o Gilardi & Co LLC, P.O. Box 808054, Petaluma, CA 94975-8054

More Information This notice does not describe all the lawsuit's details. All papers filed in this case can be inspected at: Clerk, U.S. District Court, 100 Federal Plaza, Central Islip, NY 11722. Additional information, including a more detailed notice, is at: WWW.INSURANCECLASSACTION.NET

DO NOT ADDRESS QUESTIONS TO THE CLERK OF THE COURT OR THE JUDGE.

DO NOT CALL METLIFE OR YOUR AGENT ABOUT THIS NOTICE OR THE CASE.

FOR QUESTIONS VISIT WWW.INSURANCECLASSACTION.NET OR CALL 800-961-8147.

SOURCE Law firm of Stamell & Schager, LLP

The mother of an autistic child joined Consumer Watchdog and its attorneys today to announce a lawsuit against the California Department of Managed Health Care ("DMHC"), the Schwarzenegger Administration agency responsible for regulating many of California's health insurers. The suit alleges that the DMHC has wrongfully allowed insurance companies to refuse to pay for autism treatments, resulting in the denial of critically needed, medically necessary treatment for autistic children.

The suit, filed by Consumer Watchdog and Strumwasser & Woocher LLP, alleges that the DMHC, and its Director Cindy Ehnes, recently changed the state agency's policy to permit insurers to deny coverage for Applied Behavioral Analysis ("ABA"), an essential treatment for autism, in plain violation of the California Mental Health Parity Act. That law requires health insurers to cover and pay for all medically necessary treatments for autism, including ABA. If successful, the suit would require the DMHC to bar insurers from refusing to cover medically necessary ABA treatments. The suit also seeks to compel the DMHC to turn over records that would expose the full extent of the DMHC's violations of the California Mental Health Parity Act and the Knox-Keene Act.

"Californians, including those stricken by autism, and their parents and caregivers, expect regulators to enforce the law, not to side with insurance companies seeking to boost their profits by denying patients the care they need," said Harvey Rosenfield, founder of the non-profit advocacy group Consumer Watchdog and author of the landmark insurance reform initiative Proposition 103. "Governor Schwarzenegger, a longtime and vocal supporter of the Special Olympics and developmentally disabled children, will now have to explain in court why his administration is allowing health insurers to evade state mental health laws and shift health care costs to already beleaguered taxpayers."

Governor Schwarzenegger, who appointed the current Director of the DMHC, has received $711,200 in campaign contributions from Blue Cross, Kaiser and Blue Shield -- three health insurers regulated by the DMHC that commonly deny coverage for autism treatments.

The DMHC's actions upholding heath insurance denials for medically necessary autism treatment puts children at risk by forcing parents to seek treatment through over-stretched taxpayer-funded programs, or to forgo treatment altogether.

"HMOs and health insurers are denying autistic children the most effective medical treatment that is available, with severe consequences for them, their families, and the state's taxpayers," said Fredric D. Woocher, lead counsel in the suit. "Insurance companies are blatantly violating California law. Yet the Department of Managed Health Care is not only standing by and doing nothing to prevent these violations; it is actually supporting the insurers as they abandon autistic children and their families."

Insurer's New Tactic in the Battle to Avoid Paying for Autism

ABA is a form of behavioral therapy that has been scientifically proven to improve brain function in autistic children. For years, insurance companies refused to pay for ABA on the grounds that it was "experimental" and that there was insufficient medical evidence to show that it was an effective treatment for autism. But the evidence supporting the efficacy of ABA is now overwhelming. The Centers for Disease Control and Prevention, the National Institute of Mental Health, and the United States Surgeon General all agree that behavioral interventions, such as ABA, are a critical component of any comprehensive autism treatment program.

According to the lawsuit, until March of this year, health care consumers were able to appeal an insurer's denial of ABA through the DMHC's Independent Medical Review ("IMR") system, in which a treatment denial is reviewed by a team of doctors that is unaffiliated with the insurance company that denied the treatment and independent of the DMHC.

The suit alleges that as the IMR doctors increasingly overturned insurer treatment denials, compelling the insurers to pay for ABA, insurers privately urged the DMHC to change its procedures and process the treatment denials through the DMHC's own internal grievance review system. Unlike the IMR system, in which independent doctors evaluate whether a treatment should be provided on the basis of whether it is medically necessary and effective, the grievance system is conducted by DMHC staff, who are not doctors and who simply defer to the insurers' determination of whether the claim is even covered by their health care policies.

"Health insurers want to re-write the law to benefit their bottom line and the regulators are holding the pen," said Pam Pressley, Consumer Watchdog's Litigation Director. "California's mental health laws are clear: doctors get to decide whether care is needed, not insurance company bureaucrats or government lawyers."

Consumer Watchdog has learned that the health insurance industry mounted a lobbying campaign to convince the Schwarzenegger Administration that ABA is an "educational" program not covered by health insurance policies. On March 9, 2009, the DMHC issued a memo indicating that the agency would review ABA and other autism treatment denials through the DMHC's internal grievance system as urged by insurers.

Consumer Watchdog has evidence that the DMHC has in fact upheld the insurers' denials of ABA on coverage grounds in violation of the Mental Health Parity Act. That law requires insurers to pay for any "medically necessary" and effective autism treatment -- a decision that must be made by independent doctors, not by insurance company bureaucrats or government lawyers.

Kristie Sepulveda Burchit, mother of Aidan who suffers from autism, joined the group to announce the lawsuit. Kristie's insurer, Blue Cross, first refused to provide ABA in 2008 on the ground that it was not medically effective as a treatment for autism. Kristie requested an IMR and the independent physicians who reviewed her appeal overturned the Blue Cross denial. Then, in 2009, shortly after the DMHC issued its March 9 memo, Blue Cross again refused to pay for Burchit's continued ABA autism treatment, this time on the basis that it supposedly was "not covered" by Kristie's health insurance policy because ABA is an "educational service." Burchit has now appealed the denial to the DMHC through the grievance system and is awaiting a decision from the regulator. Consumer Watchdog said that if it wins the lawsuit, the DMHC would have to order Blue Cross to provide ABA treatment for Aidan.

The suit also alleges that the DMHC and its Director Cindy Ehnes:

• Illegally instituted a policy of denying ABA treatment on the ground that providers were inadequately licensed, despite the fact that the law clearly requires health insurers to cover all medically necessary treatments for autism, including ABA, whenever such services are either provided or supervised by a licensed or certified professional.
• Illegally withheld public documents properly requested under the California Public Records Act, which would expose how the DMHC conducts its "grievance system" and would reveal the full extent of the DMHC's violations of the mental health parity law.

Nearly 1 out of every 150 children born in the United States is diagnosed with autism. As of December 2007, the California Department of Developmental Services provided care to nearly 37,000 Californians with autism.

SOURCE Consumer Watchdog

Katzman Garfinkel Rosenbaum won a $20 million verdict against QBE Insurance Company in Miami on February 13, 2009. Two weeks of testimony in Federal court resulted in the largest verdict ever against QBE for hurricane damage. The residents of Buckley Towers condominium association are ecstatic after having their claims denied since 2005. Founding Partner, Alan Garfinkel who heads up the firm's Insurance Disputes and Natural Disaster Law practice group is based in Central Florida. Their law firm represents thousands of hurricane victims and community associations throughout the state.

"Taking a closer look at repairs needed that were caused by the 2004 devastating hurricanes may help condominium associations on Central Florida, who are struggling to meet financial obligations in this economy," stressed Mr. Garfinkel. Florida law allows policy owners up to five years from the date of loss to file or re-open hurricane insurance claims. It is critical that associations, homeowners and businesses impacted by the storms of 2004 get a second opinion on their insurance claim. "You may have walked away from insurance proceeds that are rightfully owed to you, Insurance companies are hoping you forget that you still have rights to assert a claim, or believe that your claim did not exceed the deductible," Garfinkel went on to say.

DEADLINE FOR ANYONE QUESTIONING WHETHER THEIR CLAIMS WERE PROPERLY ADJUSTED OR THOSE WHO NEVER FILED CLAIMS ARE:

HURRICANE CHARLIE: STATUE OF LIMITATIONS - AUGUST 12, 2009

HURRICANE FRANCES: STATUE OF LIMITATIONS - SEPTEMBER 3, 2009

HURRICANE JEANNE: STATUE OF LIMITATIONS - SEPTEMBER 25, 2009

The statutory deadlines for damages caused by these hurricanes is quickly approaching. Boards, particularly new ones not seated at the time of the hurricanes, would be well advised to have their property inspected as soon as possible. This will ensure they were paid in full by their insurance company or provide ammunition needed to recover amounts still owed. For more information regarding the statutory deadlines for hurricanes Charlie, Frances and Jeanne, please visit our website at www.kgrlawfirm.com or call us toll free at 1 800 393 1529.

Attorney Garfinkel will hold a press conference next week to answer questions regarding this unprecedented verdict and to also provide critical information to families and condominium associations questioning whether their claims were properly adjusted.

SOURCE Katzman Garfinkel Rosenbaum