Tag: Insurance

Judge rules against insurer that fired adjuster after comp claim
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Judge rules against insurer that fired adjuster after comp claim

A federal judge in Chicago on Tuesday ruled against an insurance company’s summary judgment in a suit filed by a former employee fired after an 11-month, unresolved workers comp claim.
Timothy Buhe worked as a claims adjuster for Lincoln, Rhode Island-based Amica Mutual Insurance Co. when in early 2013 he fell off a roof while investigating a homeowner’s claim, according to court documents in Timothy Buhe v. Amica Mutual Insurance Co., filed in U.S. District Court in Illinois’s Eastern Division.
In discussions with two Amica representatives, Mr. Buhe indicated he needed at least two surgeries and was “confused” by the company policy on disability leave, according to court documents.
Complicating matters, Mr. Buhe ran a mortgage business on the side, one which his employer had known about.
In November, an adjuster with Amica’s workers comp insurer Chubb Ltd. contacted the company to inform them that Mr. Buhe had been surveilled and was working for his own company while collecting workers compensation.
In 2016, Mr. Buhe filed for bankruptcy, failing to disclose his workers compensation claim and subsequently claimed he did not know he was supposed to, according to court documents.
Judge Jorge Alonso ruled in part against the summary judgment, finding merit in both claims related to the ADA and retaliatory termination: “…A disability leave of absence that an employee seeks as a reasonable accommodation ‘is a factual issue well suited to a jury determination,’ ” his ruling stated.
He also found that “a reasonable jury could conclude that the real reason for plaintiff’s termination was not the violation of company policy but the fact that plaintiff had filed a workers compensation claim against defendant.
A jury could reasonably conclude that Amica seized on the pretext of a violation of company policy as soon as it presented itself in order to terminate plaintiff, but that the real reason for the termination was retaliatory animus against plaintiff for pursuing a workers compensation claim.
There is a genuine issue of material fact as to plaintiff’s claim of retaliatory discharge, and defendant’s motion for summary judgment on this claim is denied.” Judge Alonso granted the summary judgment related to the estoppel claim, as Mr. Buhe voluntarily requested to dismiss this part of his suit, according to court records.

Judge rules against insurer that fired adjuster after comp claim
Welfare

Judge rules against insurer that fired adjuster after comp claim

A federal judge in Chicago on Tuesday ruled against an insurance company’s summary judgment in a suit filed by a former employee fired after an 11-month, unresolved workers comp claim.
Timothy Buhe worked as a claims adjuster for Lincoln, Rhode Island-based Amica Mutual Insurance Co. when in early 2013 he fell off a roof while investigating a homeowner’s claim, according to court documents in Timothy Buhe v. Amica Mutual Insurance Co., filed in U.S. District Court in Illinois’s Eastern Division.
In discussions with two Amica representatives, Mr. Buhe indicated he needed at least two surgeries and was “confused” by the company policy on disability leave, according to court documents.
Complicating matters, Mr. Buhe ran a mortgage business on the side, one which his employer had known about.
In November, an adjuster with Amica’s workers comp insurer Chubb Ltd. contacted the company to inform them that Mr. Buhe had been surveilled and was working for his own company while collecting workers compensation.
In 2016, Mr. Buhe filed for bankruptcy, failing to disclose his workers compensation claim and subsequently claimed he did not know he was supposed to, according to court documents.
Judge Jorge Alonso ruled in part against the summary judgment, finding merit in both claims related to the ADA and retaliatory termination: “…A disability leave of absence that an employee seeks as a reasonable accommodation ‘is a factual issue well suited to a jury determination,’ ” his ruling stated.
He also found that “a reasonable jury could conclude that the real reason for plaintiff’s termination was not the violation of company policy but the fact that plaintiff had filed a workers compensation claim against defendant.
A jury could reasonably conclude that Amica seized on the pretext of a violation of company policy as soon as it presented itself in order to terminate plaintiff, but that the real reason for the termination was retaliatory animus against plaintiff for pursuing a workers compensation claim.
There is a genuine issue of material fact as to plaintiff’s claim of retaliatory discharge, and defendant’s motion for summary judgment on this claim is denied.” Judge Alonso granted the summary judgment related to the estoppel claim, as Mr. Buhe voluntarily requested to dismiss this part of his suit, according to court records.

Insurance legislators reintroduce physician dispensing model law
Welfare

Insurance legislators reintroduce physician dispensing model law

Reprints Louise Esola The National Council of Insurance Legislators’ latest model law on pharmaceutical reimbursement in workers compensation is a reintroduction of a 2013 model law that represents a new push to help educate more state lawmakers on the importance of reining in drug costs for injured workers, according to the organization’s leader.
The model law aims to re-establish clear guidelines for doctors when it comes to reimbursement and distribution of drugs to help reduce workers compensation insurance costs, according to a draft of the Workers Compensation Pharmaceutical Reimbursement Rates Model Act included in NCOIL’s spring meeting agenda, set for March 2-4 in Atlanta.
It zeros in on physician dispensing and drug compounding in workers compensation — issues states are grappling with, NCOIL CEO Tom Considine told Business Insurance from his office in Manasquan, New Jersey.
“We believe this is a hidden accelerator in health costs,” he said, echoing the sentiments of many in comp circles who believe physicians dispensing drugs can raise costs significantly.
1846, which introduced physician prescribing rules, during the 2013-14 session of the Pennsylvania House of Representatives.
She could not be reached for comment.
NCOIL’s model law aims to get more states on board with change, Mr. Considine said, adding that NCOIL is now in the process of tallying which states enacted laws based on the organization’s 2013 adopted model law on the practice of physician dispensing.
Twenty-two states have limits on physician dispensing practices, according to data gathered in early 2017 by Matrix Healthcare Services Inc., then doing business as MyMatrixx and recently acquired by Express Scripts Holding Co.
A spokeswoman for the Washington-based National Association of Insurance Commissioners told Business Insurance that model laws can be effective in inspiring change.
The act also limits physician-distributed drugs to no more than a first fill within seven days from the date of injury, according to the draft.

S.D. bill aims to prevent lawsuits against comp insurers, employers
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S.D. bill aims to prevent lawsuits against comp insurers, employers

Reprints Louise Esola Lawmakers in South Dakota are slated Tuesday to hear about proposed legislation that would prevent injured workers from suing their employers, workers compensation insurers and third-party administrators on bad faith claims.
S.B.
145, sponsored by a total of 21 state senators and representatives, will leave bad faith claims up to the state’s Department of Labor and Regulation, which oversees the state’s workers compensation program, and would ensure that an employee receives that which is due.
Currently, parties involved in workers comp claims can be sued in civil court if an employee finds that he or she has been treated unfairly.
The department, if it finds favor in the employee’s claim, can “allow the employee a reasonable sum for attorney’s fees to be recovered and collected as part of the costs following a separate hearing of record,” according to a draft of the legislation.
“No person may bring or maintain a cause of action in relation to workers’ compensation benefits sounding in tort or in contract against any employer, employer who is self insured, a risk sharing pool, a third-party administrator, or any insurance company, including any reciprocal or interinsurance exchange, based on a wrongful act, omission, wrongful denial or any claim for refusal to investigate a claim or pay a loss that was considered vexatious, without reasonable cause, or in bad faith,” the draft states.

Insurance legislators planning model law for physician dispensing
Welfare

Insurance legislators planning model law for physician dispensing

The National Council of Insurance Legislators is gearing up to adopt a model law that would provide guidance for states that wish to tackle such issues as physician dispensing and drug compounding in workers compensation.
The model law aims to establish clear guidelines for reimbursement of pharmaceutical products in order to help reduce workers compensation insurance costs, according to a draft of the Workers Compensation Pharmaceutical Reimbursement Rates Model Act included in NCOIL’s spring meeting agenda, set for March 2-4.
One component of the act would permit an employer, their workers compensation insurer or their designated third-party administrator, under certain conditions, to restrict reimbursement for pharmaceutical products to a directed network of preferred pharmaceutical providers.
This aims to rein in on physician dispensing, a practice comp experts have long pegged as costly.
The act also limits physician-distributed drugs to no more than a first fill within seven days from the date of injury, according to a draft of the act.
The act will also limit compound medications, requiring a “critical evaluation, physician documented medical necessity or utilization review of compounded pharmaceutical products prescribed for patients,” according to a draft of the act.

Data breaches for comp insurers inevitable, preparedness key: Experts
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Data breaches for comp insurers inevitable, preparedness key: Experts

The workers compensation industry should anticipate and be prepared for data breaches, experts say.
“The bad guys are getting more and more sophisticated and any form of cyber security always has a human element that is dependent on people following certain steps and procedures.” In November, SAIF Corp., Oregon’s state-chartered workers comp insurer, was victim of a data breach when an unauthorized third party illegally gained access to a SAIF premium auditor’s email account from a phishing attack.
SAIF is not the first workers compensation organization to fall victim to a data breach.
Companies have to pay attention to the vulnerabilities that exist before a data breach occurs because of the type of personal information that can be accessed, experts say.
“Insurers have different obligations because of the information that they store and the volume of information, especially when it comes to workers comp,” said Jennifer Rothstein, New York-based senior director, cyber security at Kroll Associates Inc. “With workers comp, there is a lot of (personally identifiable information) and (protected health information) that is collected, and because you are dealing with employees of an organization, that might trigger notification obligations, credit monitoring and other remediation.
Workers comp requires a review of medical records … that may trigger some (Health Insurance Portability and Accountability Act) protections.” There are many risks to be aware of, experts say.
You may have all sorts of computer systems that communicate with physicians, hospitals and other insurers,” said Alan Brill, New York-based senior managing director, cyber security and investigations, at Kroll.
“First is reporting requirements, depending on what type of information is subject to breach and where company and information owners are located,” said Michael Hindelang, Detroit-based partner, data security and privacy litigation at Honigman Miller Schwartz & Cohn L.L.P.
In the case of SAIF, insurers have taken steps to respond to the breach.
We have not received reports that any information has been used to commit identity theft.”

Vermont is best state for insurance: Report
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Vermont is best state for insurance: Report

Reprints Gloria Gonzalez Vermont again has the best insurance regulatory environment, while Delaware has the worst among U.S. states, according to a new report.
Vermont has been named as having the best regulatory environment for the fourth straight year and the fifth time in six years amid developments such as Gov.
Phil Scott signing H. 85 to expand the state’s captive insurance regulatory regime to cover agency captives in May, according to Washington-based conservative think tank R Street Institute’s 2017 Insurance Regulation Report Card published Tuesday.
80 legislative package, Delaware for the first time had the worst score in the country, just narrowly edging out North Carolina, which had placed last the previous two years.
The package imposed an “onerous regulatory regime” similar to California’s Proposition 103 for home and auto insurance, according to the report.
The biggest improvements in this year’s report card were seen in Florida, Michigan, Pennsylvania and Tennessee, while the biggest declines were seen in Delaware and New Hampshire, according to the report.
Most notably, Florida’s state-run Citizens Property Insurance Corp. has seen its market share drop to just 4.3% of the market from 14.3% of the market over that span, according to the report.
“On the other side of the ledger is Delaware, which imposed significant new restrictions on underwriting freedom.
“Under the agreement, which the United States and the EU ultimately signed in September, U.S. states must eliminate statutory collateral and local presence requirements for EU reinsurers doing business in the United States.
Meanwhile, U.S. insurers operating in the EU are relieved of having to comply with certain group capital, governance and reporting requirements.”

Commercial insurance rates rise in fourth quarter
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Commercial insurance rates rise in fourth quarter

Insurance pricing increased in most commercial lines in the fourth quarter of 2017, although rates for workers compensation continued to fall, according to insurance exchange Ivans Insurance Solutions.
Commercial auto insurance premium renewal rates increased by 3.1% on average in the fourth quarter, the Tampa, Florida-based unit of insurance technology firm Applied Systems Inc. said Wednesday in a statement.
Commercial auto insurers have reported poor results for the past two years, and the average commercial auto premium renewal rate increased 2.9% for all of 2017.
Florida saw the biggest annual rate hike with a 5.2% average increase in 2017.
Commercial property rates increased 2.9% in the fourth quarter and 3.1% for the full year.
Policyholders in Florida and Texas, which were hit hardest by hurricane losses in 2017, experienced different responses from insurers.
Average property premium rates in Florida increased 1.4% in 2017, and rates in Texas increased 4.1%, according to Ivans.
General liability rates increased 1.9% in the fourth quarter, and rates for business owner’s policies, which are package policies bought by small businesses, increased 3.9% in the quarter.
Umbrella rates increased 1.3%, compared with 1.5% in the third quarter, and workers compensation rates fell 2.3% in the fourth quarter, compared with a 1.2% decline in the third quarter.

Calif. former agent sentenced for stealing $100,000 in premiums
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Calif. former agent sentenced for stealing $100,000 in premiums

A former Moreno Valley, California-based licensed insurance agent was sentenced Friday after pleading guilty to stealing more than $100,000 in insurance premiums.
Frederick Donald Rollins, while working as a licensed agent at an insurance agency, collected premium payments from multiple clients for workers compensation and commercial general liability coverage, but did not place coverage with an insurance carrier, the California Department of Insurance said Friday in a statement.
The California DI launched an investigation after receiving multiple complaints, including “one from an insurance carrier after a company attempted to file a claim for its injured employee under what turned out to be a nonexistent policy number and the other from a business owner who discovered they had no legitimate workers compensation or liability coverage,” according to the statement.
Mr. Rollins has been sentenced to one year in an “alternative sentencing, hard-labor program,” the DA’s office said, and ordered to pay $100,363 in restitution to his victims.
“Many people make the mistake of thinking insurance fraud is a victimless, white-collar crime,” said Insurance Commissioner Dave Jones.
“This agent left his clients at great financial risk when he failed to secure their policies, leaving them without the coverage they paid for.”

Florida opens delinquency proceedings for allegedly insolvent insurer
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Florida opens delinquency proceedings for allegedly insolvent insurer

Florida’s Office of Insurance Regulation is asking the state’s chief financial officer to initiate delinquency proceedings against an insurer underwriting workers compensation, claiming the company “is impaired or insolvent” or “is about to become insolvent,” according to a letter issued Friday.
Fort Lauderdale, Florida-based Guarantee Insurance Co. issued financial statements in June claiming $42.4 million in surplus; a later audit instead found a deficit of $236,775, according to the letter addressed to CFO Jimmy Patronis of the Florida Department of Financial Services in Tallahassee.
The letter also states the company, which is owned by Fort Lauderdale-based Patriot National Inc., “is found by the office to be in such a condition or is using or has been subject to such methods or practices in the conduct of its business, as to render its further transaction of insurance presently or prospectively hazardous to its policyholders, creditor, stockholders, or public.” The letter also claims the company has been a victim of fraud, stating that at least $15.7 million of the company’s cash was transferred to the company’s owner Steve Martin, who owns Patriot National, with “no documented business purpose and no discernable benefit” to the Florida insurer.
Calls for comment to Guarantee Insurance were directed to Patriot National, where press officials could not be reached for comment.
According to Guarantee Insurance’s website, the company writes workers comp insurance and is licensed in 34 states as well as the District of Columbia.