Florida Insurance Law Blog : Florida Insurance Lawyer & Attorney : Mark Nation Law Firm : Orlando, Longwood, Gainesville

Federico A. was involved in a serious car accident and as a result suffered extensive physical injuries. He was transported to the hospital for several emergency surgeries. The hospital promptly submitted his medical bills to his PPO health insurance company, Blue Cross and Blue Shield of Florida, for payment. The treatment had been rendered by a physician who did not participate with Blue Cross as one of its preferred providers (a "non-PPO provider"). Blue Cross denied many of the bills claiming that an assistant surgeon who was utilized in the multiple surgeries was not necessary.  Those bills which Blue Cross did pay were significantly reduced to what Blue Cross refers to as its "allowance."

Federico was referred to us by his personal injury attorney for assistance with his substantial medical bills. Based on prior experience, I believe that current version of the Blue Cross Blue Shield of Florida's PPO policy and the payments made thereunder violate Florida Statutes Sections 627.6044 and 627.6471. Section 627.6044 requires a PPO insurer to specifically identify in the insurance contract the methodology it uses to pay claims. The Blue Cross PPO policy does specifically identify numerous factors which it says will be evaluated in determining the appropriate "allowance." However, in reality, Blue Cross does not utilize any of those factors, and instead relies on only one undisclosed factor. I also believe that the Blue Cross PPO insurance policy violates section 627.6471, by reimbursing non-PPO providers at a rate lower than allowed by law, and by requiring the insureds to pay coinsurance in excess of the statutory maximum.

In addition, after conferring with the treating surgeon, I felt confident that we would be able to prove the necessity of an assistant surgeon for the various procedures.

Based on these factors, I filed suit against Blue Cross for breach of contract. Discovery ensued, but within one week of taking the adjusters' depositions, Blue Cross agreed to settle the case by paying the doctor’s bills.

As part of the settlement, Blue Cross agreed to reduce its lien against the personal injury proceeds from $270,000 to $10,000.  (For more information on reducing and waiving liens, you can search this blog for the word "lien.") Blue Cross also agreed to pay all of my attorneys fees and costs incurred in investigating and prosecuting the case.

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Our client was traveling in the Middle East when she fell and suffered a serious injury. She was treated at a local hospital but required medical evacuation back to the United States.

Before her trip, our client purchased a travel insurance policy before leaving on her trip. The policy provided for emergency evacuation benefits up to $50,000.00. The insurer refused to pay the full value of the emergency evacuation arguing that our client should have travel back to the Untied States on a much cheaper, commercial stretcher flight. Litigation continues.

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The demographic and workforce study, "Mapping the Future - Estimating Florida Again Services Needs 2008 to 2030," recently concluded that Florida's 85-and-over population is forecast to grow by 126 percent in the next 22 years. This huge increase is on top of the fact that Florida already has the highest percentage of senior citizens in the United States.

This sharp increase points out the growing need for Long Term Care Insurance for Florida's citizens. Along with the increase in the issuance of Long Term Care policies, I have seen an increase in denials of claims.  There are two ways insurance companies pay benefits under a long-term care policy.  The policy might pay a fixed dollar amount per day (known as "indemnity based coverage") or the policy might pay certain actual expenses you incur (known as "expense based coverage").

These policies and their terms are extensively regulated by Florida Statutes Section 627.9401 - 9408, as well as Florida Administrative Code 69O-157.001 - 304. These statutes and regulations set forth the minimum benefits that must be offered under Long Term Care policies, as well as establishing how these long term care policies can be marketed, and sold.

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I recently filed suit against Mega Life (again) to help my client recover health insurance benefits.

This company has been sued many, many times for failing to pay health benefits. In fact, Mega Life's parent company, HealthMarkets, Inc., recently received a $20,000,000 fine from 29 states as a result of a 3 year multi-state investigation which found numerous problem involving consumer disclosure, agent training and, claim and complaint handling practices.   The state of Florida will receive more than $1.8 Million from this settlement.

Mega Life is an Oklahoma insurer that claims it is entitled to certain protections set up by our Florida Statutes for "out-of-state group plans." In order to avail itself of the protections set up in the Florida Statutes for these out-of-state groups, Mega Life issues a "master policy" to a company that Mega Life actually set up. Consumers are then encouraged to by Mega Life agents to become "members" of the company that Mega Life sets up. Mega Life then promises that by being members of this company, consumers will be entitled to lower rates and quality health insurance benefits.

Unfortunately, our Florida statutes do provide certain protections to these out of state insurers that are not available to other health insurers. However, to be eligible for these protections, Mega Life must strictly comply with the criteria set forth in the statute.  I don't believe Mega Life complies.  One of things that Mega Life must prove is that their insurance benefits are "reasonable in relation to the premiums charged thereunder and the issuance of the group policy has resulted, or will result, in economies of administration." Florida Statute 627.6515(2). In this case, I have retained an insurance actuary to investigate whether Mega Life's health benefits comply with this requirement.

In our current case, Mega Life is denying the claim for health insurance benefits because, according to Mega Life, our client's condition is a "pre-existing condition." The problem for Mega Life is that even if the condition is "pre-existing," the law in Florida, the District of Columbia (which is the law that Mega Life says applies), and the federal law, all mandate coverage for pre-existing conditions. Thus, even if Mega Life proves our client's condition is pre-existing, Mega Life will still be on the hook for the medical expenses.
 

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Many times, when a lawyer for a personal injury victim settles his or her client's personal injury case, the health insurer will ask for a significant portion of the settlement for reimbursement of expenses which it incurred in paying for health care. This is known as "subrogration" or a "right of reimbursement." 

Repeatedly, I have seen cases where good attorneys pay back liens that do not even exist, or they pay back way too much. Paying back liens that don't exist, or paying back too much is a disservice to our clients, and can be considered malpractice. The law on health insurance liens is complicated and one should not dabble in it unless experienced.

Frequently, personal injury attorneys will recommend their clients to hire The Nation Law Firm to negotiate those liens.  This referral removes any potential liability from the personal injury attorney, and provides a much needed service to their clients.

Recently a nationally recognized personal injury law firm asked me to deal with a $650,000 health insurance lien on a case they were trying to settle. After intense negotiations I convinced the health insurance carrier to accept $65,000 as payment in full for the lien. Had the insurer not agreed, I was prepared to file a declaratory judgment action to seek a judicial determination of the amount of the lien. If I was successful in the declaratory judgment action, the insurer would have not only had to reduce or eliminate the lien, but would have also been responsible for my attorney's fees and costs.

I am currently in litigation in numerous such declaratory judgment actions at this time.

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