San Francisco Insurance Law Blog

What can I do about a denied insurance claim?

When making a homeowners' insurance claim, you trust the company you work with will find a satisfactory resolution to your problem. However, this is not always the case. Insurance claims are often denied, or pay out less than you're expecting. Nerdwallet explains some of the steps you can take to dispute a denied insurance claim. 

Insurance policies are often confusing and filled with jargon that a layperson might have a hard time understanding. That's why your first step should be to review your policy in detail to determine whether your claim is indeed covered. This will give you a better understanding of the denial and whether it was warranted. Don't immediately assume that the insurance company is correct. Insurance companies often make mistakes, and these mistakes cost policyholders quite a bit of money.

Beware of disability claims coded as sick vs. injured

Insurance company bait-and-switch trick cuts off LTD benefits at age 65

Many professionals and high earners purchased long-term disability insurance decades ago. They were relieved that the LTD policy kicked in later when they had to stop working because of a disabling condition.

Supreme Court asked to weigh in on forum selection clauses

Among the many benefits offered to employees by companies in California is the ability to participate in a retirement plan such as a 401K. These are often governed by the Employee Retirement Income Security Act. What many employees may not be aware of is that if they ever disagree with the benefits they are to receive under an ERISA plan, their employer might be able to dictate the court that would have jurisdiction over the matter with no regard whatsoever to the where the employee works or lives.

As explained by Bloomberg Law, a provision called the forum selection clause allows companies to identify the court of their choosing when addressing benefits disputes with employees. This is something that the United States Department of Labor does not believe is fair and that should change. Some people have tried to change this already. However, to date, at least four different federal appeals courts have essentially upheld an employer's right to choose the court for any benefit dispute. These are the Third, Sixth, Seventh and Eighth Circuit appeals courts.

Another Landmark Victory Against Travelers Insurance

State court ruled CGL policy exclusion was too ambiguous to enforce

The law firm of Pillsbury & Coleman LLP prevailed again in ongoing litigation against Traveler’s Insurance on behalf of a commercial policyholder. A California state court ruling, the first of its kind, declared that Travelers could not rely on a vague policy exclusion to shirk its duty to defend its insured.

Are PTSD triggers real?

Insurance companies in California may be more reluctant to pay long-term disability benefits to individuals whose symptoms are not measurable and quantifiable. If you suffer from post-traumatic stress disorder, you may have difficulty convincing an insurance company that certain conditions trigger your symptoms. Adjusters and others who work for the insurance company may accuse you of malingering, that is, faking your symptoms to receive benefits. 

Nevertheless, according to Web MD, the relationship between triggers and PTSD symptoms is very real. Because many triggers are objectively harmless things, insurance companies may be reluctant to recognize that they provoke your symptoms. However, it is not the inherent danger that the triggers themselves present that instigates the response. Rather it is their association with the traumatic event that has formed in your mind, often without your realizing it. 

Do you have a bad faith claim on your hands?

Californian residents like you rely on your insurance for vital, every-day things. This can include medical procedures, medication, routine doctor visits, and other things that your life and well-being rely on. When insurance companies refuse to honor their policies, it can be a huge blow.

Not all states have the same requirements for something to be considered bad faith. As FindLaw shows, conduct without proper cause - or with unreasonable cause - can be considered bad faith behavior in some. Other states have a more specific definition that can make it hard for you to get compensated if your claim is considered to be "relatively debatable". However, there are two common elements that must be present in all bad faith cases.

How insurance companies investigate a disability claim

If you have long-term disability insurance, either privately or through your employer, in California, you expect to be able to use it if an accident occurs that puts you out of work. Unfortunately, it is in the insurance company's best interest to deny your claim and they oftentimes go to long lengths to "prove" your disability is not that bad. It may help to know how they investigate claims and what you can do to improve your chances of approval. 

According to the National MS Society, when you file a disability claim the burden of proof is on you, so it is important to take the right steps. Before even filing, start filling out a diary of your symptoms or restrictions on a daily basis. Separately, make a list of all the specific requirements you have at work and how your disability interferes with them. Make an appointment with your doctor and bring all that information with you so you can work together to strengthen your claim. 

What is ERISA, and what does it do?

Even if you enjoy your job in California, you probably do not want to do it forever. Like many employees, you probably have aspirations of retiring someday. To that end, you may participate in a pension plan that provides benefits when you stop working, but you may have doubts or fears about your ability to access that money when the time comes.

According to FindLaw, the Employee Retirement Income Security Act affords you, as an employee, more information about your pension than you would have had access to in the past. It prevents plan administrators from making excessively risky investments and requires them to act in the best interests of you and other plan participants.

What are the elements of insurance bad faith?

Bad faith occurs when one party of a legal contract acts dishonestly to avoid fulfilling his or her contractual obligation. Bad faith may also occur when one party enters a legally binding agreement without any intention or the means to fulfill it. California, like most other states, recognizes an "implied covenant of good faith and fair dealing," which means that a party injured by the bad faith dealings of another may sue the offending parties for damages that result from the bad faith actions. Many parties across many industries are guilty of bad faith, but those within the insurance industry are particularly notorious for bad faith dealings.

According to FindLaw, insurance agencies are bound by common law torts theory, which states that insurance providers owe their policyholders a duty to act in good faith and fair dealings given the special nature of their relationship. FindLaw further details two elements you, if you hope to win a common law claim of bad faith, must prove.  

Important elements of disability insurance

Most people who live and work in California would find it financially challenging to suddenly be without their paychecks for an extended period of time. This may happen if a person is laid off or gets fired from their job but it also may happen if they become sick or injured and are not able to go to work. These situations may arise from a variety of events that have nothing at all to do with their job but nonetheless preclude a person from performing that job.

It is times like these when having a disability insurance policy is something a person becomes very grateful for. As explained by NerdWallet, there are two primary types of these policies: short-term disability insurance policies and long-term disability insurance policies. As the names imply, the biggest difference between these policies is what type of disability they cover based on how long a person remains disabled.

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