Actual Sample Health Insurance Case
A 59 year old man suffered a stroke. His wife requested $9,600 in benefits under his health insurance policy. The insurance company denied the claim immediately, without conducting any investigation, although it claimed in a letter to the wife that the claim had been given "careful consideration." The wife submitted the claim three more times. The company failed to obtain accurate and complete medical records, conducted no independent investigation, and failed to fairly evaluate the medical evidence it possessed. The company continued to deny the claim by clinging to a restrictive definition of "accident" as used in its policy. The company tried to convince the couple that the company had diligently sought to validate and honor their claim, but could not do so because the event upon which the claim was based was not covered by the policy. The man and wife sued for bad faith and were awarded their policy benefits, $200,000 in compensatory damages, and $6,000,000 in punitive damages. Ainsworth v. Combined Ins. Co., 104 Nev. 587, 763 P.2d 673 (1989); Ainsworth v. Combined Ins. Co., 105 Nev. 237, 248, 774 P.2d 1003 (1989).
Terms
Health insurance pays the bills for diagnosis and treatment of covered medical conditions. There are different types of health insurance plans.
Preferred Provider Organizations (PPOs)
Preferred Provider Organizations (PPOs) use "preferred" medical care providers; you get a list of providers and you get to choose who you see. If you use a medical provider that isn't on the list the plan will pay less or perhaps none of the bill depending on the policy language.
Health Maintenance Organizations (HMOs or Managed Care)
Health Maintenance Organizations (HMOs) require members use medical providers affiliated with the HMO. Members make the health care decisions and coordinate referrals to medical specialties. The medical providers may be employees of the HMO or contract providers. HMOs operate in specific areas and limit coverage for care obtained outside the HMO network or coverage area except for emergencies.
Copayment
A payment the insured must make directly to the medical provider for medical service or goods, in addition to the plan membership fee. For example, $5 for each doctor's visit.
Deductible
The amount the insured must pay before the insurance company will pay.
Preexisting Condition
A disease, illness, or injury the insured received treatment for some period before applying for health insurance.
Usual and Customary
The insurance company will generally pay the usual and customary charge, i.e., the usual fee charged by a majority of like providers in the same area.
I Can Help You Through the Oftentimes Confusing, Frustrating, Difficult Process.
If you are not able to locate the information you need, please do not hesitate to give me a call. You can also use the quick "Contact Us Today" form located in the left border of this page. Simply fill in your name, title, phone, email, and your question, then click on submit and I will get back to you as soon as possible. The "Contact Us" button in the main menu will take you to a more comprehensive request for information. I want to hear from you, I want to be of help. Remember, I want you to receive fair treatment and you can talk to me about your concern for free. |
|
|
