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Texas ERISA And Bad Faith Insurance Law Blog

Bad faith insurance smarts

The tragedy of Hurricane Harvey may be fading into the background for many Americans, but for those affected by this natural disaster, the challenges unfortunately have continued. One of the biggest topics surrounding this event involved insurance. Would hurricane victims find coverage? Many Texans have become wary of bad faith insurance and other deceptive speedbumps along the way, but there are some smarts to keep in mind in regard to this process.

When it comes to natural disaster, state officials can not only provide sound information, but a peace of mind. The Texas Department of Insurance shares that, depending on the extent of the damage, residents may need to file for more than one insurance claim. Currently, the Department's website states that officials have extended the deadline for flood claims to one year. However, the real work can begin when residents connect with flood insurers to assess the situation. Those suspicious of bad faith insurance may want to pay special attention to the details of homeowners insurance policies. Although most policies do not cover flood damage, residents may still decide to file a claim.

What you should do when filing a property insurance claim

When a home is damaged due to a disaster such as a storm, tornado, or flood, the stress and emotional turmoil may cause a person to unwittingly do things that will adversely affect a property insurance claim.

The fact is, how a person proceeds in this situation makes a huge difference in how – or if – the claim is covered. Following are some dos and don’ts when it comes to filing a property insurance claim.

What Can I Do If My Insurance Claim Is Denied?

If your homeowner’s insurance claim has recently been rejected in San Antonio, you may be wondering what the next steps should be. In this case, it’s important to keep your wits about you and react in a calm and reasonable manner. Fox Business describes the proper way to handle rejected insurance claims so that you can achieve the best results possible.

Read Through the Denial Letter

Identifying common claim filing errors

Like many of the physicians and practitioners in San Antonio that we here at The Law Office of Jessica Taylor, PLLC have worked with in the past, you rely heavily on insurance reimbursement to meet the operating expenses of your practice. That is why having a claim denied by an insurer can be so frustrating. The immediate response of both you and your staff upon receiving a denial may be to prepare a lengthy medical opinion in preparation for an appeal. Yet before you do that, your first step should be to check for simple filing errors that may have affected payment. 

In most cases, it is these simple errors that lead to denials. The website ACPInternist.org has prepared a list of some of the most common types of filing errors, as well as recommendations on how to avoid them: 

  • Incorrect subscriber ID numbers: Making sure that your front office staff asks to see a patient's insurance card at every visit ensures that the right subscriber ID is attached to a claim. 
  • Coordination of Benefits errors: Always ask if a patient is double covered, or if another potential payer (e.g., auto insurance, workers compensation) should receive his or her claim first. 
  • Diagnosis coding not matching coverage determinations: Compare the diagnosis assigned to national and local coverage determinations to see if the care provided meets medical necessity guidelines. 
  • Incorrect provider information: Make sure that the tax identification number, the national provider identification number, the employer identification number and place-of-service code on the claim are correct. 
  • Ineligible patients: Insurance pre-authorizations ensure that you know if a patient is still eligible for coverage. 
  • Duplicate claims: Always keep all claims submissions on file to avoid duplicates. 

Do insurers have to inform you why they denied coverage?

Just like any other responsible adult, you know that when you get behind the wheel of a car you need to be insured in compliance with Texas law. Yet when you sought out an insurer, that insurer denied you coverage and refused to provide you with a policy. Not only did they deny you coverage, but they ignored your inquiries into why. Are insurance providers legally allowed to deny such information to consumers?

According to the Texas Consumer Bill of Rights, no, they are not. Insurers are legally obligated to provide consumers with a written statement detailing why you were denied coverage, including a factual list of any incidents that influenced this decision. Insurers are also required to provide legitimate sources for any research data, studies or cited statistics that influenced this decision. If an insurer denies you the right to know why you were denied, you may be able to take legal action.

Understanding the ERISA claims process

At The Law Office of Jessica Taylor PLLC in Texas, we know that while you love the retirement and insurance benefits your employer provides you through the Employee Retirement Income Security Act, you dread dealing with ERISA's stringent federal and state rules and regulations when you have to make a claim.

No one denies that ERISA law is incredibly complex and not easy to navigate on your own. But what good are your benefits if you cannot collect them? You deserve to have access to your ERISA benefits, and the first thing you need to understand is that you must do everything exactly right when you file an ERISA claim.

Sinkholes prompt battle between residents and insurer

People in San Antonio rely on their homes to not only protect them from the elements, but also to provide them and their families with a safe haven from which they can escape the stresses of their jobs and other responsibilities. When damages to their homes render them incapable of providing those benefits, that reliance shifts to their insurers to correct said damages and restore residents' peace-of-mind. One can imagine, then, just how disheartening it may be for one in such a situation to learn that his or her insurer has no intention of providing the relief he or she is seeking. 

Not merely one, but 83 property owners in Florida are currently having to struggle with such a predicament. Their problems began back in 2010, when signs of sinkhole activity began to appear around their condominium community. As the problems worsened, resident's (through the homeowners' association) began filing insurance claims. The company insuring the community, however, has denied all of the claims it has received. No explanations were given for the initial denials, yet subsequent claims have been denied based off of new legislation passed in Florida in 2011 (the HOA correctly points out, however, that the law should not apply in this case since it did not exist when the community bought its policy). 

What are timely filing limits?

Healthcare providers in San Antonio (such as yourself) rely heavily on insurance reimbursement to be able to continue to serve their patient populations. It could easily be said, then, that you are somewhat at the mercy of insurance companies and their policies. Dealing with claim denials is a constant struggle for providers in your position. This struggle can be compounded even further in that the longer it takes to get claims resolved, the greater the potential that you encounter timely filing issues. 

Timely filing refers to the standard that insurance companies hold providers like yourself to for getting claims submitted. These time limits are meant to expedite the claim process. If you do not meet them, claims will not be covered. What is more, you typically cannot bill patients for claims that were denied due to timely filing. According to the Modern Medicine Network, the timely filing deadlines for some of the more common carriers are as follows: 

  • Medicare: 365 days
  • Blue Cross/Blue Shield: 365 days
  • Medicaid: 95 days
  • United Healthcare: 90 days

Why long-term disability claims are denied

The Employee Retirement Income Security Act (ERISA), which became law in 1974, allows those who become disabled and unable to work to receive long-term benefits. However, applying for these benefits is a complex process, and there are countless reasons why such benefits are denied.

What are some common reasons why claims are denied, and what can be done to avoid these mistakes?

What is Section 404(c) of the ERISA act?

ERISA, the federal Employee Retirement Income Security Act, is a law that protects Texas employees’ private pension plans, such as the 401(k) and the 403(b). Another part of the law addresses 404(c) plans, which allow employees to manage their retirement account investments themselves instead of a fiduciary, who makes investments on behalf of employees in other plans.

Employees who feel qualified to make investment decisions or who want to be in charge of their own funds may consider the 404(c) so they can direct the amount of savings to invest in different types of companies. Additional reasons some may want to self-direct their investments is so they can follow their religious or moral tenets and avoid investing in companies they may object to, such as those that conduct animal testing or are owned by groups of another faith.

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