*Ignoring insurer denials?

When a San Jose woman was about to get her disability benefits cut off and appealed to the California Department of Insurance, she was told to try Indiana, where the policy had been written. "They said, 'If the [insurer] offers you any money, its best to take whatever they offer because it doesn't look like you have a very good case,'" the woman said. (A doctor hired by the insurance company claimed that she was not disabled.) But Indiana regulators had a different take and got the insurer to keep paying out benefits. The question, of course, is why she needed to have regulators in another state look into the matter. The Daily Journal's Evan George reports that the state Insurance Department resists taking even simple steps to help claimants fight denials. When George asked a department spokesman about the San Jose woman, the response was, ""She came for help, we directed her to the right place." Not a great answer.

In most cases, when a worker who has paid for disability benefits files a claim, the insurer will review it and pay. But some cases - markedly those where the insured reports suffering from complex symptoms like chronic pain or long-term injuries of the back, neck and spine - are denied, even if treating physicians and the Social Security Administration find them disabled, the Daily Journal has found. The result is that workers who believed they had a safety net find themselves fighting for benefits at the same time they are dealing with health problems and medical bills.

Some insurers no doubt try to weasel out of paying claims - and it's the state's job to flesh out those cases. But it's not easy, and insurance companies are not always to blame. From L.A. Daily:

A Sunland interior designer plead guilty to two counts of fraud this week after he had claimed disability to the tune of more than $147,000 and an insurance company worker happened to catch the man on television -- working. Ronald E. Hunt, 56 continued working as a designer even as he claimed to be unable to work. But an employee with an insurance company paying his disability claim spotted him on an HGTV home improvement show and told the California Department of Insurance.

Actually, these sorts of cases are not unusual, especially when it comes to back and neck injuries that can be hard to pinpoint. As to how many folks with legitimate cases get shafted, well, who knows? And that's part of the problem. Of course, that shouldn't let CA officials off the hook. From the Daily Journal:

California officials say they do not always have the power to intervene in individual cases, but insist that they don't turn everyone away. How often does the department get involved? It's impossible to know because the Department of Insurance doesn't keep track, a spokesman said. Although the agency said it does track how many complaints it receives about disability insurers: roughly 500 each year. [Insurance Commissioner Steve] Poizner's office has initiated no major investigations or enforcement actions and has levied only one fine against these insurers since he took office in 2007. The department denied a public records request from the Daily Journal to review consumer complaints and Poizner declined an interview.

This guy is running for governor?

*Insurance Department spokesman Darrel Ng wanted to clarify the process by which complaints are received. First off, he says, not all policies covering Californians are primarily regulated in California. From his email:

If you work for a large company that's headquartered in, say, Boston and they offer you health insurance, your policy is governed by the master policy of that company and the state it's issued in. In this case, it would be a Mass. Insurance Company. The best place to file a complaint with would be with the Mass. Department of Insurance. We receive hundreds of thousands of calls every year to our consumer hotline (800-927-HELP) and strive to serve every person who calls. Sometimes that action includes Insurance Commissioner Steve Poizner calling an insurance company CEO to get results. Sometimes that means referring people to the correct regulator.

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Mark Lacter
Mark Lacter created the LA Biz Observed blog in 2006. He posted until the day before his death on Nov. 13, 2013.
Mark Lacter, business writer and editor was 59
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