Mansell, Engel & Cole

Oklahoma City Insurance Law Blog

Appeals court: insurer can't act contrary to clear policy terms

The following story conveys precisely the kind of news regarding insurance companies that makes legions of policyholders wary and even fearful when dealing with them.

Imagine that you have a health policy with a big-name national insurer. Owing to a bank glitch, your last calendar payment of the year is not credited for December.

Mental health claims often denied coverage

When it comes to mental illness, many people in Oklahoma and nationwide suffer in silence. After all, while some illnesses or injuries clearly manifest themselves in ways that make it apparent that the person is hurt or sick, mental illnesses generally carry no physical monikers. Yet, this does not mean that they are no more or less serious than other types of illnesses.

Unfortunately, some insurance companies do not always see things this way. In fact, insurance claims for mental illness treatments are denied at a greater rate than other types of claims. A National Alliance on Mental Illness survey revealed that in 2015, almost 30 percent of respondents covered by private medical insurance under the Affordable Care Act had a claim for mental health care denied. The reason cited for the denial was that it was not a "medical necessity." This is more than twice as many as those whose general medical care claims are denied. When this happens, people with a mental illness are often forced into the difficult situation of either paying for mental health treatments on their own or going without treatment altogether.

Don't be shaken if an earthquake hits: Know what to do beforehand

Nowadays, it's growing more and more common to hear stories of natural disasters occurring in Oklahoma or elsewhere in the nation. You may have already experienced crazy weather where it's warm at one part of the day then drops to near-freezing temperatures just hours later. You may be one of many who have taken to carrying several types of clothing in your car to accommodate any unexpected changes you might encounter during your travels.

In addition to strange weather patterns, there also seems to be an increased risk for hurricanes and earthquakes in some areas. The key to survival in such circumstances often lies in how much you know ahead of time regarding how to stay safe and how to recover your losses if you suffer property damage or economic loss in a storm.

A potential problem for long-term disability claimants

If you are disabled and collecting payments under a long-term disability policy, that's pretty much a done deal, right?

That is, there should be no challenge to your claim by an insurer once you have -- and continue to be -- medically verified as unable to perform your customary work owing to injury or illness.

The case for subrogation in catastrophes

Subrogation action is an important insurance concept to understand. With subrogation, one party stands in for another party when making a claim for damages. For example, if you’re driving down the road and another driver runs a red light and side swipes you, your insurance provider may pay for your damages. However, because the other driver was at fault in the accident, your insurance company—acting in your place—will seek reimbursement from that driver’s insurance provider. This scenario is one of the most common types of subrogation.

It makes logical sense to pursue subrogation action in cases where there is a clear third party at fault. However, when natural disaster strikes, such a case is generally considered an “Act of God” event with no clear, tangible culprit.

The troubling reality of denied claims for paying policyholders

It happens all the time.

It is quite common, in fact, for an individual in Oklahoma or another state who dutifully complies with health care policy requirements to be flatly denied coverage by an insurance company.

What can you stand to win in a bad-faith insurance claim?

The law holds insurance companies to a certain standard of behavior. When such a company’s conduct does not live up to this standard, it is coined “bad faith practice”. There are various types of conduct against an insured party that constitute bad faith. For example, it is considered bad-faith practice if the insurer:

  • Neglects to fully investigate a policyholder’s claim,
  • Refuses to pay for damages or excessively delays payment,
  • Offers to compensate for less than the actual value of damages or
  • Fails to provide all available policy information that could benefit the policyholder.

Aetna's coverage rejection scorned by legion of critics

A teen-aged girl living with epilepsy-linked seizures had high hopes a couple months ago in the days immediately preceding scheduled surgery to relieve her of her life-altering symptoms.

Her procedure -- minimally invasive surgery called laser ablation -- has a string of documented successes in persons with epilepsy. A recent CNN article on the surgery states it is "safer and more precise than traditional brain surgery."

Uninsured motorists can disrupt your life

In Oklahoma and nearly every other state, driving without minimum insurance coverage is against the law. Insurance provides assistance in paying for property damage and injuries following a car accident. Because Oklahoma is an at-fault state, the driver who is determined to be responsible for the accident is the one whose insurance covers the damages.

There are good and bad elements to this. On the positive side, an accident won't affect your premiums if the other guy causes it. On the negative side, the amount of coverage the responsible driver carries limits the amount of your compensation. If the responsible driver is one of the 30 million drivers on the road who have no insurance, you may be out of luck.

What is an “act of God” for insurance claims purposes?

Insurance policies are complex contracts. These contracts provide the basis for the agreement made between the company and the policy holder. These policies are often comprised of various provisions. Many of these clarify when damage is covered and when it is not. One example included in many policies is “act of God” provisions.

What is an “act of God” provision? Essentially, these types of provisions are used by insurance companies to cover damage caused by natural disasters. It is important to note that the policy may or may not use the term “act of God.” Other terms that could indicate this type of provision is present include perils, catastrophes or disasters.

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