Insurance Companies Hurting Doctors and Patients

A recent 5th Circuit opinion  exposed what is an all too familiar problem for doctors and their patients: health insurance companies refusing to pay for treatment after expressly authorizing the treatment.

According to the 5th Circuit, this scenario "is reenacted each day across the country" and usually unfolds as follows:

• A patient visits their doctor to receive treatment for a medical condition.  
• The doctor diagnoses the condition and recommends a medical treatment plan. 
• For some patients the medical treatment plan may require additional treatments, surgery, and medical devices (implants, prosthetic, other equipment.)
• The doctor then contacts the patient's insurance company to see if the requested treatment is covered under the patient's health insurance policy.
• If the patient's health insurance policy confirms that the treatment or device is covered the doctor then proceeds with the treatment.
• The doctor then sends a bill to the patient's health insurance for the services or treatment provided, but the insurance company refuses to pay what it had previously agreed was covered.
• The doctor then may seek reimbursement from the patient who is unlikely to be able to pay for this unplanned financial burden, which can uncomfortably transform the patient/doctor relationship into the debtor/creditor relationship.  

The good news for doctors and patients is that the 5th Circuit has now decided that even health insurance companies that issue group policies, or ERISA policies, which are normally regulated by a more lax federal law, can now be held liable under more stringent Texas Insurance and Consumer laws.

Therefore if you are a Texas doctor or Texas patient whose health insurance has authorized medical treatment only to deny coverage after you received treatment, you may have a claim against the health insurance company who is now denying coverage.   

Bounce House Hazards; Special Alert to Parents

A 2009 memo from the Consumer Product Safety Commission ("CPSC") estimated that there were over 31,000 emergency department treated injuries associated with inflatable bounce houses in between 2003 and 2007 in the U.S.- that's over 17 trips to the emergency room a day.

The CPSC's memo also revealed that during that same period there were four reported deaths, most of which involved someone falling off or out of the inflatable and then hitting their head on the hard pavement nearby.

Now as summer vacations get underway parents will undoubtedly be hosting or taking their children to birthday parties or gatherings with inflatable bounce houses.  While these bounce houses look soft, safe, and fun for children of almost any age the CPSC's data tell a different story, and  a recent article in the Washington Post revealed several shocking stories of how improperly staked bounce houses have been blown across city streets, swept away by wind gusts, or toppled by excessive weight.

Before letting your child enter a bounce house or other inflatable jumping device make sure to check that:

1. The inflatable is properly secured and staked; 
2. The inflatable is not over crowded with children;
3. The inflatable is not tattered, worn or patched; 
4. Your child is never unattended and someone is always watching the inflatable; and
5. The air flow from the motor to the inflatable is not obstructed. 

Tornadoes and Severe Weather Damage Waco area

According to local news reports golf-ball sized hail, torrential rains, strong winds, and tornadoes pounded Waco, Texas and surrounding areas including Lacy Lakeview, Mart, and China Spring on Tuesday evening.

Here is a link to a Tornado Safety Guide published by the National Weather Service which includes a discussion on how to recognize the signs of a tornado before it's too late to react.

If you or a loved one have been affected by severe weather you may want to consider following these steps (most of which are adapted from the Tornado Safety Guide) which are essentially the same as those for persons involved in car crashes:

1. Safety First.  Always make sure you and your family are safe. If you are in a secure building remain inside in an interior room away from windows until you can confirm that it is safe to leave your shelter.   If you or a loved one is injured seek immediate medical attention. Watch for power lines -they may still be carrying high voltage, and be mindful for broken glass and debris on the ground. Do not use matches or lighters because they may spark natural gas that is in the air from ruptured lines.

2. Wait for Emergency Personnel to Arrive. In Waco or McLennan County you may find information about emergency services here.

3.  Document any Damage to Your Property.  If you are able you will want to start securing your personal property and your home to prevent further damage and documenting what property is damaged.

4. Contact Your Insurance.  As soon as you are able contact your insurance company.  During severe weather situations insurance companies often get over-whelmed with phone calls and claims which means that any delay in presenting your claim may delay any necessary repairs.  Unfortunately, some insurance companies do not always agree to cover all of the damage that is caused by severe weather.  Sometimes this is due to a limit or exclusion in the policy and sometimes it is due to an insurance company acting in bad faith.  If you have questions about how your insurance company is handling your claim you should consider contacting a trial attorney who specializes in consumer and insurance law.

Car Insurance: Are You Covered?

In most states, including Texas, it is mandatory for drivers to be insured for car accidents they cause (referred to as minimum liability coverage).   However, most drivers' experiences confirm the necessity of having additional insurance coverages to not only protect themselves from being sued for accidents they cause, but also to avoid paying out-of-pocket when a driver who caused an accident either had no insurance or insufficient insurance to cover their injuries and damages.

In Texas there are actually 8 different types of auto insurance coverages you can purchase, each with different limits of coverages.  In fact, the Texas legislature has deemed Personal Injury Protection and Uninsured/Underinsured Motorist coverages so important that if a consumer does not want those types of coverage the consumer must specifically reject those coverages in writing.

It is not only important for you to be familiar with the types of coverage you have purchased and their limits, but also to be familiar with the coverages you have rejected, as well as any endorsements and exclusions which further limit your coverage.

In addition to basic liability coverage, most drivers should consider purchasing the following types of insurance:

1. Medical Payments Coverage

What it pays: Your medical and funeral bills resulting from accidents, including those in which the other person is a pedestrian or bicyclist.

Who it covers: You, your family members, and passengers in your car, regardless of who caused the accident.

2. Personal Injury Protection (PIP) Coverage

What it pays: Same as medical payments coverage, plus 80 percent of lost income and the cost of hiring a caregiver for an injured person.

Who it covers: You, your family members, and passengers in your car, regardless of who caused the accident.

An insurance company must offer you $2,500 in PIP, but you can buy more. If you don’t want PIP, you must reject it in writing.

3. Uninsured/Underinsured Motorist (UM/UIM) Coverage

What it pays: Your expenses from an accident caused by an uninsured motorist or a motorist who did not have enough insurance to cover your bills, up to your policy’s dollar limits. Also pays for accidents caused by a hit-and-run driver if you reported the accident promptly to police.

• Bodily injury UM/UIM pays without deductibles for medical bills, lost wages, pain and suffering, disfigurement, and permanent or partial disability.
• Property damage UM/UIM pays for auto repairs, a rental car, and damage to items in your car. There is an automatic $250 deductible, which means you must pay the first $250 of the repairs yourself.

Who it covers: You, your family members, passengers in your car, and others driving your car with your permission.

Insurers must offer UM/UIM coverage. If you don’t want it, you must reject it in writing.

4. Collision (Damage to Your Car) Coverage (If you still owe money on your car, your lender will require you to maintain collision and comprehensive coverages.)

What it pays: The cost of repairing or replacing your car after an accident. Payment is limited to your car’s actual cash value, minus your deductible. Actual cash value is the market value of a car like yours without damages.

Who it covers: You, your family members, passengers in your car, and others driving your car with your permission.

5. Comprehensive (Physical Damage Other than Collision) Coverage

What it pays: The cost of replacing or repairing your car if it is stolen or damaged by fire, vandalism, hail, or a cause other than a collision. Comprehensive coverage also pays for a rental car or other temporary transportation if your car is stolen. Your policy won’t pay for an auto theft unless you report it to police. Payment is limited to your car’s actual cash value, minus your deductible.

If you still owe money on your car, your lender will require you to have collision and comprehensive coverage.

Description of Insurance coverages from the Texas Department of Insurance

Crash: You're in a Car Accident. What are you supposed to do next?

According to the U.S. Department of Transportation, there were an estimated 5,505,000 police-reported traffic crashes in the United States in 2009.  While you hope to never be involved in crash, you know that no matter how careful and attentive a defensive driver you may be, you can't control whether others obey the rules of the road.

So if you do find yourself as one of the millions of people who are in an accident every year  it's good to follow these simple rules:

1.  Safety First. If you're able to move your vehicle out of harm's way do so immediately.  If not, turn off your engine, put on your hazard lights, keep your seat belt on, call an emergency or police number, and wait for emergency personnel to arrive.  Allow medical professionals and emergency personnel to assist you, and if you experience pain or discomfort after the accident seek medical care.

2.  Call the Police.  Even in a minor accident it is good to have a police officer create a crash report.  In Texas, the reports look like this.  Make sure to get the police officer's name, badge number, and an incident or case number.  To formally request a copy of a police report in Texas you can complete and send to the Texas Department of Transportation this form, known as Form CR-91, Request for Copy of Peace officer's Crash Report.

3. Exchange information with the other driver.  You will want to get the other driver's name, driver's license number, license plate number, the make and model of the other car, and the other driver's insurance information including the name of the insurance company, the policy number, and a phone number for filing an insurance claim.  It's important to ask if the driver is also the owner of the other car -if not ask for the owner's name and insurance information as well. Some people keep a blank "accident form" in their glove box along with other accident materials like a disposable camera, pen, and paper.  Here is a sample accident form.

4. Document the Accident.  If you are able, you will want to use your cell phone camera or another camera to take pictures of both your car and the other car from a series of angles including the front, back, sides, and views that look at each corner of the car. If there are any witnesses you should get their name and contact information as well.

5.  Contact Insurance.  As soon as you are able, contact your insurance company and the other driver's insurance company.  Some people prefer to have a personal injury trial lawyer make this contact on their behalf.  If you decide to hire an attorney to represent you in your claim you should investigate the attorney and their firm to see if they have experience in handling insurance claims for property damage and personal injury. Also remember that if you are injured you will in all likelihood not know the full extent and lasting effect, if any, of your injuries immediately after the accident so be careful not to agree to a quick settlement with an insurance company before you've received appropriate medical treatment.