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Showing posts sorted by relevance for query insurance. Sort by date Show all posts
Showing posts sorted by relevance for query insurance. Sort by date Show all posts

Monday, September 22, 2014

NJ insurance adjuster admits to role in defrauding Turnpike Authority

Today's post is shared from northjersey.com/

A insurance adjustor with a Little Falls firm on Monday pleaded guilty to his role in a two-year scheme to defraud the New Jersey Turnpike Authority and several insurance companies of $900,000, U.S. Attorney Paul J. Fishman announced.

Robert Napolitano, 54, of Clifton, the owner of Dawn to Dusk LLC, an insurance adjusting company in Little Falls, admitted to one count of mail fraud. His sentencing has been scheduled for Jan. 8 in federal court in Newark.

Napolitano was accused of conspiring with a former turnpike authority employee to withhold money from claims for property damage caused by motorists.

In October 2011, he entered into a secret agreement with Gerardo A. Blasi, then a claims manager at the turnpike authority, to investigate accidents on the toll road and determine the cost of repairs to agency property, authorities said.

Napolitano would then submit the repair cost to the motorist’s insurance company on behalf of the turnpike authority, but without its permission, and request that the payment be made to his company. The complaint alleges that three insurance checks listing the turnpike authority as the claimant were mailed to Dawn to Dusk between October 2011 and January 2012, but Napolitano’s company never sent the money, totaling $230,000, to the turnpike authority.

The scheme worked by taking advantage of a change in the authority’s policy after the agency decided it would no longer attempt to recover...

[Click here to see the rest of this post]

Thursday, January 29, 2015

New Clues on Google’s Plans for Insurance




The Google Compare auto insurance shopping site has been up and running in the United Kingdom for two years.
The Google Compare auto insurance shopping site has been up and running in the United Kingdom for two years.

The insurance industry takes it for granted that Google will soon introduce its Google Compare auto insurance shopping site, which has been in Britain for two years, in the United States. Yet, despite a whole lot of spadework, the effort has continuously been delayed.
But in a note on Thursday, Ellen Carney, an analyst with Forrester Research, produced a summary of where the operation stands. Ms. Carney used the fact that a Google employee recently became a licensed insurance agent on behalf of a presumed Google competitor to speculate that the effort might be delayed because Google was about to buy (or has already bought) a San Francisco insurance agency as a means of entering the California market.
“As late as last month the site was expected to launch in California, to be followed in Q1 2015 with likely launches in Illinois, Pennsylvania, and Texas. Last I heard was that California pilot wouldn’t begin until sometime in Q1,” Ms. Carney wrote, speaking about Google Compare’s presumed introduction in the United States.
According to Ms. Carney, Google has spent more than two years pitching insurance companies on Google Compare, a site that aims to let people do an easy comparison of auto insurance rates. In Britain, the site has shoppers enter their license and registration number, after which Google presents a list of insurance...
[Click here to see the rest of this post]

Wednesday, July 15, 2020

Workers’ Compensation Insurer Responses to COVID-19


This free NIOSH Center for Workers’ Compensation Studies (CWCS) webinar will highlight the ways that many insurers are responding to COVID 19:
  • Communicating prevention programs
  • Providing funding for engineering controls and PPE
  • Providing remote risk control services

Friday, August 8, 2008

CMS Gearing Up for Mandatory Insurance Reporting

CMS will implement mandatory insurance company reporting: GHP January 1, 2009 and liability insurance carriers (workers’ compensation) on July 1, 2009. Mandatory reporting announcements will be posted on the CMS web site and e-mail notices may be requested by e-mail

The new provisions for Liability Insurance (including Self-Insurance), No-Fault Insurance, and Workers' Compensation found at 42 U.S.C. 1395y(b)(8):

Add reporting rules; do not eliminate any existing statutory provisions or regulations. The new provisions do not eliminate CMS' existing processes if a Medicare beneficiary (or his/her representative) wishes to obtain interim conditional payment amount information prior to a settlement, judgment, award, or other payment.

Include penalties for noncompliance.

Who must report: "an applicable plan." "…[T]he term 'applicable plan' means the following laws, plans, or other arrangements, including the fiduciary or administrator for such law, plan or arrangement: (i) Liability insurance (including self-insurance). (ii) No fault insurance. (iii) Workers' compensation laws or plans."

What must be reported: the identity of a Medicare beneficiary whose illness, injury, incident, or accident was at issue as well as such other information specified by the Secretary to enable an appropriate determination concerning coordination of benefits, including any applicable recovery claim.

When/how reporting must be done:

• In a form and manner, including frequency, specified by the Secretary.

• Information shall be submitted within a time specified by the Secretary
after the claim is resolved through a settlement, judgment, award, or other
payment (regardless of whether or not there is a determination or
admission of liability).

• Submissions will be in an electronic format.

Monday, November 8, 2010

California Applicants' Attorneys Association Announces New Legislative Team

The California Applicants’ Attorneys Association (CAAA), whose members represent Californians injured on the job, today announced a new legislative advocacy team. CAAA President Barry Hinden said, “CAAA is announcing a new team that will be a strong voice on behalf of the rights and dignity of Californians injured while doing their jobs. Our legislative team looks forward to working with all stakeholders to insure that insurance carriers pay to heal workers’ on-the-job injuries and income support while disabled. Over the past six years many families have been left without medical care or disability compensation due to changes demanded by Governor Schwarzenegger. We look forward to working with the new governor, legislature and the workers’ compensation community to make changes to restore balance, and make the system work more effectively and efficiently by reducing unnecessary delays and costs.”

Hinden announced the following legislative representation team:

Mike Herald – Legislative & Policy Advocate – Mr. Herald, an attorney, has spent the past two decades advocating on behalf of low income Californians in the State Capitol while representing the Western Center on Law & Poverty. “My experience representing struggling California families has shown me how important it is people injured at work receive adequate insurance coverage. Workers’ compensation insurance is to provide workers the opportunity to heal, knowing they won’t lose their home or drown in debt. It is in everyone’s interest to have adequate insurance so that costs for injured workers do not fall upon the taxpayers. I look forward to collaborating with legislators, administrators and stakeholders to improve the workers’ compensation insurance system.” Mr. Herald will be CAAA’s lead legislative representative in the Capitol.

Richie Ross – Legislative and Political Consultant – Mr. Ross, a longtime California labor advocate and campaign consultant, has advised CAAA for more than 15 years. He will now serve as political and legislative consultant, advising CAAA on strategy, lobbying, and political contributions and campaigns. “I look forward to strengthening CAAA’s alliances with organized labor, civil rights and consumer organizations. Californians injured at their jobs often have difficulty getting insurance companies to pay their legitimate claims.  There are many others who face similar obstacles. And when insurance companies don’t meet their obligations, it is the taxpayers who end up footing the bill. Californians want to prevent that cost shifting.”

Sen. Martha Escutia (Ret.) – Legislative Counsel – "The Senators (ret.) Firm - legislative counsel: founded by former Senators Martha Escutia and Joe Dunn, the firm brings extensive legislative and political experience to the CAAA team. In fact, Senators (ret) Escutia and Dunn were two of the three "no" votes in the State Senate on SB899. Sen. Escutia (ret) will serve as the lead partner from The Senators Firm for CAAA. Ms Escutia, trained as a civil rights attorney, and said, “I look forward to using my experience in advocating for the civil rights of women and minorities on behalf of those injured at work. Those injured on the job often have their medical care delayed or denied, and their permanent disabilities are largely uncompensated, and insurance companies discriminate in apportioning disability compensation. I intend to involve diverse California communities in efforts to improve California’s workers’ compensation insurance system, and seeking fair compensation and prompt, quality medical care.”
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For over 3 decades the Law Offices of Jon L. Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered work related accident and injuries.

Monday, November 25, 2013

California Workers' Compensation Rates Going Up in 2014

Despite the fact that recent legislation in California limited access to the Worker's Compensation system even further, and imposed medical treatment review procedures without the availability of an adversary system, worker's Compensation rates are increasing in 2014.
Insurance Commissioner Dave Jones today adopted an advisory average pure premium rate of 2.70 dollars per 100 dollars of employer payroll for workers compensation rates effective January 1, 2014.

The adopted amount is lower than that proposed by the Workers' Compensation Insurance Rating
Bureau of California's (WCIRB). The WCIRB's proposed advisory average rate was $2.75 per $100 of payroll.

The WCIRB's proposed advisory average pure premium rate is 8.7% ($2.75 per $100 of payroll) above the industry's average filed rates as of July 1, 2013 and the adopted pure premium rate ($2.70 per $100 of payroll) is 6.7% above the industry's average filed rates as of July 1, 2013.

Commissioner Jones, the WCIRB and the public members' actuary all agree that the overall impact of SB 863 (2012) continues to result in savings for the workers' compensation system.

The California Department of Insurance continues to observe that medical and indemnity losses are outpacing wage growth and consequently, the average advisory pure premium will increase in 2014.
Media Note:
  • The commissioner's pure premium decision is advisory only. Pursuant to California law, the commissioner does not set or have authority over workers' compensation insurance rates. The commissioner's advisory pure premium rate is not predictive of what an individual insurance company may charge its policyholders because the review of pure premium rates is just one component of insurance pricing. 
  • Workers' Compensation Insurance Rating Bureau of California

Friday, May 30, 2014

Intentional Fraud

All fraud is not actionable in workers' compensation. It is similar to discrimination action actions under the workers' compensation act. There is much talk, but few claims succeed, since they are based upon the element of intent.

This case caught my eye because of David DePaolo's recent blog post highlighting the recent, as David calls it, "Truly Imaginative" behavior of an individual playing two sides of the plot line.

The fraud issue struck a note for me as I have been reviewing cases for an upcoming seminar on workers' compensation issues. The decision of Bellino v Verizon, 2014 WL 10301786 (NJ App Div 2014) is a factual situation that seem to draw the ire of many insurance companies and employers. The injured worker failed to disclose some past medical information during a proceeding. The Court held that the element of intent was not proven.

Cases involving fraud are especially fact sensitive. Rarely does someone play both sides of the story line in perpetrating an intentional workers' compensation fraud scheme. Carlos Perry in West Virginia did so as the US Justice Department reports:

Knoxville Man Sentenced To Twelve Years Imprisonment For Workers' Compensation Fraud

Carlos Perry Found to Have Defrauded Six Insurance Companies Out of $401,649 in Benefits

FOR IMMEDIATE RELEASE
May 20, 2014
ABINGDON, VIRGINIA – United States Attorney Timothy J. Heaphy announced today that Carlos Perry, 58, Knoxville, Tenn. was sentenced last week in the United States District Court for the Western District of Virginia in Abingdon to twelve years in federal prison.

Perry was also ordered to pay restitution in the amount of $324,914.70. Perry had previously pleaded guilty to one count of mail fraud.

According to evidence presented at the sentencing and guilty plea hearings by Assistant United States Attorney Zachary T. Lee, between January 2011 and February 2014, Perry developed a scheme in which he defrauded six different insurance companies of workers’ compensation benefits using false business and fictitious employees.  An investigation by the United States Secret Service determined that Perry’s scheme entailed Perry impersonating an owner of six fictitious businesses located in Wise, Va., Johnson City, Tenn., Bristol, Va., and Abingdon, Va., in order to obtain workers’ compensation insurance.  Perry then filed false injury claims on behalf of the fictitious employees. 

Perry received the checks sent by the insurance companies and impersonated the fictitious employees at doctor’s visits and in communications with the insurance companies.  The United States Secret Service discovered that Perry utilized nineteen fictitious identities in the course of his scheme and used the social security numbers of numerous real persons to execute his fraud.  On January 29, 2014, Perry was arrested by the United States Secret Service and the United States Marshals Service at a doctor’s office in Kingsport, Tenn., where he was impersonating one of the fictitious employees.  As a result of Perry’s scheme, six separate insurance companies sustained a combined loss of $401,649.66. 

The investigation of this case was conducted by United States Secret Service, United States Marshals Service, and the Virginia State Police.  Assistant United States Attorney Zachary T. Lee is prosecuting the case for the United States.
.........

Monday, October 26, 2009

Denial Rates: An Insurance Company Tactic That Compounds the Health Care Delivery Problem

As Congress considers changes in the nation’s health care program, US health insurance companies continue to be scrutinized. The methodologies of how insurance companies deny claims are being investigated.

A certified nurse assistant, Amelia Mendoza, age 52, of West Covina, California, was attacked twice in the same week by a patient while working at Huntington Hospital in Pasadena earlier this year. Amelia suffered injuries that resulted in her suffering a stroke in April, falling into a vegetative state and contracting pneumonia. The hospital insurance carrier cut off medical care for her, forcing her from the hospital, and leaving her family responsible for medical care for Amelia’s work-related injury that is the hospital’s responsibility.

Her husband, Ralph Mendoza, who met with reporters and supporters outside the hospital, commented, “I am shocked and extremely disappointed that Huntington Hospital would treat Amelia this way. Amelia gave her all to her job for more than six years, and she deserves better….Amelia was injured doing her job, and the hospital has avoided its responsibility for months. I watch my wonderful wife, a mother of four children, slip away in a vegetative state and I wonder whether she would be healthy today if the hospital had met its responsibility. I want the medical care that my wife deserves.”

After an attack by a violent patient, Amelia was examined in the hospital’s Emergency Room and told to return to work. After a second attack just two days later, Amelia went to the Emergency Room and was told to go to Huntington Hospital’s in-house workers’ compensation clinic. The hospital was aware that Amelia’s blood pressure was dangerously high after the attack, and that the patient had infectious diseases. The hospital even called Amelia and her husband to warn of the health dangers Amelia faced. Yet the hospital’s clinic turned Amelia away, saying they were too busy to see her. Amelia suffered a stroke less than three hours later. The attacks had caused bleeding in her brain.

“The workers’ compensation carrier, Sedgwick, has denied liability for Amelia’s medical care, claiming that their investigation did not support a claim of injury and no medical evidence supports the claim either,” said Amelia’s attorney, Chelsea Glauber of the
Glauber/Berenson Law Firm. “Medical evidence does in fact exist which states in no uncertain terms that Amelia’s condition was caused by these attacks at work. Amelia is trapped in a horrible hell, between two insurance companies trying to avoid responsibility. So Huntington Hospital let Amelia go home, in a vegetative state, to be taken care of by her husband, who no matter how loving and well intentioned, is not qualified to provide the critical care that Amelia needs and deserves. What does it say about these insurance companies and a hospital that they would treat a hard-working human being in this awful manner?”

A
recent report on insurance companies denial rates reveals that, “When it comes to claim denials, insurers may be putting profits ahead of patients’ best interests. Most major insurance companies have reassigned their medical directors—the doctors who approve or deny claims for medical reasons—to report to their business managers, whose main responsibility is to boost profits.”


An inefficient system is not helpful to anyone, including injured workers, insurance companies, and employers. Wasteful administration should be curbed. The U.S. healthcare system wastes between $505 billion and $850 billion every year, recently reported Robert Kelley, vice president of healthcare analytics at Thomson Reuters.

Lawmakers must concentrate the U.S. health debate on how the delivery of medical care can be more efficient and effective. Delays and denials presently occurring in the workers’ compensation system continue to highlight the fact that injured workers need a universal health care system.



Tuesday, May 12, 2009

RICO Case Goes to the US Supreme Court

A Petition for Certiorari has been filed in Brown v. Cassens Transport Co., 546 F.3d 347 (6th Cir. Oct 23, 2008) (NO. 05-2089), following the rehearing and rehearing en banc denied (Jan 05, 2009). The Petition was filed on May 6, 2009. In a landmark decision of immense national significance, the US Sixth Circuit Court of Appeals ruled that a RICO claim brought by injured workers against their employer, insurance carrier and employer medical expert could proceed.

The application states:

"The Sixth Circuit's ruling that the WDCA does not involve the business of insurance is hardly a model of clarity, but it plainly rests on two central and essential elements. First, the court held that workers' compensation categorically is not insurance because, in the Sixth Circuit's view, workers' compensation does not involve a “contractual insurance relationship.” App., infra, 20a. Second, the court regarded as irrelevant Michigan's regulation of the nature of the workers' compensation benefits that must be provided by employers - including requirements imposed identically on employers who self-insure their workers' compensation risks and on those who purchase insurance of those risks - because Cassens self-insures and the court believed that self-insurance does not involve the business of insurance under the McCarran-Ferguson Act. Id. at 22a-24a. But both aspects of this analysis are wrong. They depart from this Court's precedent, will lead to inconsistent treatment of identically situated businesses, and will frustrate state policy regarding both insurance and workers' compensation."

"The issues presented here are ones of enormous practical importance: the court of appeals' holding reads significant limits into the McCarran-Ferguson Act, threatening to interfere with state insurance regulation and overturn the balance struck by States *31 in their workers' compensation systems. Most obviously, by categorically holding that state regulation of employers who self-insure their workers' compensation liability is outside the scope of the McCarran-Ferguson Act, the holding below invites a proliferation of RICO strike suits brought by aggrieved workers' compensation claimants. The attractiveness of RICO's remedies - including treble damages and attorney's fees, e.g., 18 U.S.C. § 1964(c) - and the extraordinarily burdensome nature of RICO discovery assures that an ever-increasing volume of workers' compensation litigation will find its way to federal court for decision under federal law. See, e.g., Cristin Schmitz, Employers Face RICO Claims For Workers Comp Denials, Inside Counsel (Feb. 1, 2009) (RICO permits “wide-open” discovery; plaintiffs' counsel states that if case goes to trial, “I am going to discover every single comp claim that ever existed in the past four years *** so it's going to open a real can of worms”). To the extent that settlements are not compelled in such suits, federal courts will have to pass on the merits of the underlying workers' compensation claims, creating the potential for overlapping (and possibly conflicting) adjudication of eligibility for workers' compensation benefits."

Citation:
2009 WL 1265298 (U.S.) (Appellate Petition, Motion and Filing)
Supreme Court of the United States.
CASSENS TRANSPORT COMPANY, Crawford & Company, and Dr. Saul Margules, Petitioners,
v.
Paul BROWN, William Fanaly, Charles Thomas, Gary Riggs, Robert Orlikowski, and Scott Way, Respondents.
No. 08-1375.
May 6, 2009.


Wednesday, October 21, 2009

Insuring Disabled Seniors and The Public Option


Disabled workers over the age of 65 have difficult decisions to make concerning health insurance. Those who rely upon workers’ compensation and Medicare to cover all their medical costs are in for a rude awakening. John D. Podesta and colleagues reported difficulties in the present system that seniors utilize.  “The gaps in coverage, the high cost of insurance, and the quality of care that consumers receive are the most frequently cited problems" in the present medical delivery system. Disabled workers will also have their strife compounded by the fact that Congress anticipates an increase of 15% in basic Medicare premiums next year.


Workers’ compensation insurance usually covers medical conditions that "arise out of and are in the course of employment." Treatment extends to medical care that is reasonable and related to cure the work related condition and relieve the symptoms. Workers’ compensation was not intended to any for conditions that are not work related.



Medicare provides coverage to disabled workers and those who are over 65 years of age. It does not extend coverage to those conditions that are work related. In fact, Medicare, under the Medicare Secondary Payer Act (MSP), will seek reimbursement from the injured employee for those medical conditions related to the employment, but Medicare may have accidentally or conditionally paid for.


The Federal system now keeps a tight rein to avoid duplication of benefits. As of July 1, 2009, the workers’ compensation insurance carriers are now subject to mandatory reporting of those eligible or anticipated to be eligible for workers’ compensation benefits. Medicare seeks to participate in the review of any settlement in workers’ compensation by eligible beneficiaries through an elaborate voluntary scheme of workers’ compensation set aside agreements (WCMSA).


The coverage scenario is complicated further by so called “Medigap policies” sold by private insurance companies that provide supplemental health insurance to those on Medicare for services and benefits not covered by the Federal government.  The Kaiser Family Foundation reports, that Most Medicare beneficiaries (89%) had some form of supplemental health insurance coverage in 2007. More than a third of all beneficiaries (34%) had coverage from an employer-sponsored plan, 22% were in Medicare Advantage plans, 17% purchased supplemental insurance (Medigap) policies, and 15% were covered by Medicaid (generally those with very low incomes and modest assets). Eleven percent [4.48 million] had no supplemental coverage [emphasis added].”


Those who lack coverage, avoid or forgo, medical care. Underlying medical conditions, even those that are work related, may become aggravated or accelerated. The “gap” in coverage for the some disabled workers, that exists in the system, creates additional risk factors for not only those that fall within the gap, but also as to general community health and well being.


The gap in disability insurance converge will need to be debated as Congress goes forward in the health care debate. As Speaker Nancy Pelosie (D-Calif) surveys Congress in anticipation of her final draft of a "public option," the discussion continues in Washington. A universal approach is warranted to bridge the gap for affordable and meaningful coverage.


Monday, March 4, 2013

UK - The Mesothelioma Bill - A Gift to Insurers

Historically compensation programs for asbestos victims have constantly evolved. One of the leading efforts to reform payments for victims has emerged in the United Kingdom. While the City of London continue to maintain in depth effort for employee safety and health to limit asbestos exposure and restrict disease support groups there maintain a close vigilance such as the Asbestos Victims Support Groups Forum UK [AVSGFUK]. The following article is authored by Tony Whilston, Chair of the AVSGFUK.

Asbestos victims and their representatives have welcomed the Mesothelioma Bill. After all, it is the first attempt to remedy a long-standing injustice. But, on close examination, it is a gift to insurers who could not indefinitely hide behind their own failures and evade liability for insurance they wrote for so many years. The day of reckoning has come, but at great cost to asbestos victims and with a great discount to insurers. It is in examining the detail of the payment scheme that the true cost to asbestos victims is found. This article sets out the main elements of the scheme and then discusses the Government's rationale for its generosity to insurers.

Background

For decades, insurers wantonly destroyed or simply lost records of employers' liability insurance – insurance which victims of very long latent asbestos diseases, such as mesothelioma, would later come to rely on long after the companies who exposed them to asbestos had ceased trading. Unmoved by the suffering and incalculable loss of life caused by asbestos, insurers persistently refused to accept responsibility for their failure to retain records and turned their backs on dying asbestos victims, who searched in vain for evidence of insurance which might provide some security for the families they would leave behind.

At last, in February 2010, the Labour Government consulted on measures to remedy this gross injustice with a recommendation to set up an Employers' Liability Insurance Bureau (ELIB), similar to the Motor Insurance Bureau (MIB) which pays compensation in the event negligent drivers are uninsured or insurance cannot be traced. The consultation closed in May 2010 and responsibility for responding to the consultation fell to the Coalition Government Minister, Lord Freud. Two years later, on the 25 July 2012, Lord Freud announced his response.

The Mesothelioma Bill and the Diffuse Mesothelioma Payment Scheme

Instead of creating an ELIB, the Government has drafted the Mesothelioma Bill to set up a Diffuse Mesothelioma Payment Scheme (Payment Scheme), funded from a levy on active insurers, which will pay discounted average compensation based on age to mesothelioma sufferers who were diagnosed on or after 25 July 2012. The Bill commenced in the House of Lords where the discounted payment of 70% of average compensation was increased to 75%. The Bill has now commenced its passage through the House of Commons. Royal assent is expected to be given in April 2014 and payments are set to commence in summer 2014.

It is estimated that approximately 3,500 payments will be made by 2024 at a cost of £322 million. Although average compensation in 2012 was £154,000, due to the increasing age of claimants it is expected that average litigated settlements over the first ten years of the scheme will be £124,286. At 75% of this figure, the average scheme payment would be £93,214. However, benefits and lump sum payments would be deducted in full, at an average deduction of £20,480, reducing the average payment to £72,734.

The levy will be collected by the Department of Work and Pensions (DWP) and treated as a hypothecated tax, i.e. public money. Dependants may claim under the scheme, but unlike claims in law, no payment will be made to the deceased's estate if there are no dependants. However, the scheme applies common law rules for recovery of benefits. Peers challenged the Government's very selective application of common law rules, but to no avail.

Fifty per cent of asbestos victims are excluded from the scheme, which is limited to mesothelioma sufferers only, even though it would only increase the cost by 20% to include all asbestos victims. Despite the fact that it took two years to respond to the consultation, the Government has refused to accept the modest request to set the eligibility date at the commencement of the consultation, 10 February 2010.

The scheme excludes claims for negligent environmental exposures and contaminated work clothes exposures, and claims from the self-employed. Turner & Newall (T&N) claimants, who are not protected by T&N insurance and are paid just 27% of tariff payments from T&N scheme funds, are also excluded.

The payment scheme is the result of two years' negotiation with insurers held behind closed doors in which insurers drove a hard a bargain, reducing scheme benefits well below the limit of acceptability. With threats of court action and utter intransigence, insurers have bullied and faced down the Government, thereby gaining an overwhelming advantage.

The Government expects to receive £71 million in recovered benefits and lump sum payments in the period 2014 to 2024, of which £17 million is to be given as a gift to insurers to help them out. This is a gift; it is not to be paid back. The Government is also lending insurers £30 million to help to “smooth” the first four years when there will be a spike in claims due to claims coming forward from 25 July 2012. This money will be paid back in years six and seven.

The insurers have insisted that they will pass on levy costs to businesses if the levy exceeds 3% of the annual amount they receive from employers' liability premiums, i.e. Gross Working Premium (GWP). They argue that anything over a 70% payment will exceed 3% GWP. The Government has disputed the insurers' estimates and their figures show that over the initial 10 years of the scheme, 100% compensation could be paid without exceeding 3% GWP. Nevertheless, the Government has accepted the insurers' estimates and the arbitrary 3% threshold and have pledged not to levy insurers above 3% GWP.

For the first four years of the scheme (2014-2018) insurers will have to meet the cost of claims, but the DWP will fund any cost in excess of 3% GWP. After the first four years, the DWP will have to estimate the annual cost of claims and set the levy accordingly. Any shortfall in the levy is the DWP's responsibility and any surplus will be paid into the Government Consolidated Fund. If the estimated levy payment is above 3% GWP the DWP will pay the excess, not the insurers.

Discussion

The Government justifies its concessions to insurers saying the insurers paying the levy are not necessarily the ones who took the premiums paying for untraceable historical policies so they have to be fair to them. But insurers should take collective responsibility for their collective failure. If this is “rough justice” it is nothing compared to the injustice suffered by asbestos victims.

We should be clear about where responsibility lies. The Financial Services Authority (now the FCA) described the long-standing problem of untraced insurance as “… a situation where insurers/policyholders are inappropriately subsidised by claimants ….” According to the Mesothelioma Bill Impact Assessment an estimated 6,000 mesothelioma sufferers have lost approximately £800 million in compensation due to untraced insurance. That is the extent to which mesothelioma sufferers have subsidised insurers. If one includes other asbestos victims we find that asbestos victims have subsidised insurers to the tune of £1 billion. In the face of such financial loss, not to speak of the loss of life, does fairness lie in mesothelioma sufferers continuing to subsidise insurers by 25% and other asbestos victims subsidising them by 100%?

Notwithstanding the Government's uncritical acceptance of the insurers' 3% GWP threshold, there is no certainty whatsoever that insurers will not pass on the cost to businesses at any level of GWP. The Government should not give way to threats of this sort, and certainly should not use taxpayers' money to subsidise insurers in the event of the levy exceeding the insurers' convenient 3% threshold. We have come to a pretty pass when dying asbestos victims are called on to absorb insurers' cost to protect business!

In the face of an obdurate, litigious and self-serving insurance industry, Lord Freud has negotiated a scheme at too great a cost to mesothelioma sufferers. Asbestos victims are entitled to 100% justice. We are asking everyone who is concerned about justice for asbestos victims to write to their MPs asking them to improve the Bill for mesothelioma sufferers and to give a commitment to include victims of other asbestos diseases in the scheme in the future.

Friday, December 2, 2011

Penalties for Insurance Companies Who Fail to Pay Enough for Medical Care

The quality of medical care for workers' compensation beneficiaries has always been a major issue. Injured workers just don't want to go to an employer selected physician.They want to go to a doctor who provides good quality medical care and one they have confidence in. It makes good medical sense. While one concept to adjust the issue is to compel insurance carriers to pay for outcome driven results. If the doctor cures you, then the doctor should be paid in full for the reasonable value of his or her services. If the opposite, well then maybe the doctor should get paid less.

Another approach, enacted by the federal government is to compel insurance carriers to pay a certain percentage of premiums collected for medical care, instead of paying large sums for administration expenses. That could be applied to workers' compensation carriers. Instead of paying 80% of the premium to fight the claim, workers' compensation insurance companies should be compelled to pay 80% to cure the medical condition.

Read more about this concept:
HHS Unveils Medical Loss Ratio Rule (Kaiser Health Breaking News)
"The Department of Health and Human Services today released its final medical loss ratio rule. According to an HHS press release, the rule will ensure that health insurance companies spend at least 80 percent of consumers' health insurance premiums on medical care rather than on income, overhead and marketing expenses. "If your insurance company doesn't spend enough of your premium dollars on medical care or quality improvement this year, they'll have to give you rebates next year," said CMS Acting Administrator Marilyn Tavenner, in the release . "This will bring costs down and give insurance companies the incentive to focus on what matters for patients – high quality health care."
...
For over 3 decades the Law Offices of Jon L. Gelman  1.973.696.7900  jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.

Related articles

Monday, December 27, 2021

NJ Workers’ Compensation Benefit Rates Increase in 2022

The New Jersey Department of Labor and Workforce Development (NJDOL) announced increases in the maximum benefit rates for Unemployment Insurance, Temporary Disability Insurance, Family Leave Insurance, and Workers’ Compensation for the calendar year 2022. The increased rates will be effective for new claims dated January 2, 2022, and later.

Monday, November 25, 2013

Illinois Employer to Pay $10K Penalty for Lack of Workers’ Comp Insurance

Today's post was shared by votersinjuredatwork and comes from www.insurancejournal.com

An uninsured employer in Illinois has pled guilty to a Class 4 felony for refusing to obtain workers’ compensation insurance, the Illinois Workers’ Compensation Commission announced.
John Linek, individually and as president of SMS Logistics of Chicago, has been ordered to pay a $10,000 penalty for refusing to obtain workers’ compensation insurance.
The IWCC’s Insurance Compliance Unit had been requesting compliance with the Act from this trucking firm since 2010.
In August 2013, the Compliance Division obtained a felony conviction against Ahmed Ghosien, d/b/a Ghosien European Auto Werks in Hometown. Ghosien pled guilty to a Class 4 felony for failing to obtain workers’ compensation insurance.
The IWCC’s Insurance Compliance Unit worked with the Cook County Sheriff’s Office and the Cook County State’s Attorney’s Special Prosecutions Division to obtain the conviction.
Again, the Insurance Compliance Unit had worked on the case since 2010.
Both of these individuals were given many opportunities to obtain insurance before charges were filed, but they persistently refused, the IWCC said.
[Click here to see the original post]

Monday, October 24, 2011

Insurance Agent Charged With Theft of $255,000 of Work Comp Premiums

Agents from the Pennsylvania Attorney General's Insurance Fraud Section have filed criminal charges against a Berks County man accused of the theft of more than $255,000 in workers' compensation insurance premiums.

Attorney General Linda Kelly identified the defendant as Joseph A. Maurer, 58, of 2558 Welsh Road, Mohnton. Maurer owned and operated Commonwealth Professional Group, a former insurance agency located in Reading, Berks County.

According to the criminal complaint, Maurer is accused of taking more than $188,000 in premiums paid by four municipal governments, including Bally Borough and South Heidelberg Township, located in Berks County, along with Salisbury Township in Lehigh County and Earl Township in Lancaster County. The money allegedly paid to Maurer by all four municipalities was supposed to be forwarded to Pennprime Insurance Trust, of Harrisburg, as payment for workers compensation coverage.

Additionally, Maurer allegedly misdirected premium payments for at least five other policies purchased through his agency, totaling in excess of $67,000 that was supposed to be forwarded to Travelers Insurance and ACE American Insurance Company on behalf of various clients.

Maurer is charged with three counts of theft by failure to make required disposition of funds received, all third-degree felonies which are each punishable by up to seven years in prison and $15,000 fines.

Maurer was preliminarily arraigned on October 12th before Reading Magisterial District Judge Phyllis J. Kowalski and released on $850,000 unsecured bail. He was also ordered to surrender his passport.

A preliminary hearing for Maurer is scheduled for November 9th, at 1:30 p.m., before Magisterial District Judge Kowalski.

The case will be prosecuted in Berks County by Deputy Attorney General John T. Dickinson of the Pennsylvania Attorney General's Insurance Fraud Section.

Thursday, January 8, 2015

Trucking Insurance Minimums Must be Raised to Make Our Roads Safer

Today's post is shared from justice.org/

Washington, DC—The Federal Motor Carrier Safety Administration (FMCSA) is currently considering new regulations that would raise the federal minimum insurance requirements for trucks and buses.

“This rulemaking is extremely important to help improve accountability and safety for all motorists,” said American Association for Justice President Lisa Blue Baron. “Increasing insurance minimums will help restore justice for all Americans injured by trucks.”

Nearly four thousand people die in truck crashes each year. A fatal truck crash often costs over $4.3 million, but truck drivers are only required to maintain insurance policies of $750,000. This insurance requirement was set over 30 years ago and has never been adjusted, not even for inflation.

“Outdated insurance requirements allow trucking companies to skirt responsibility and leave injured motorists and taxpayers to pay the difference,” added Baron.

Earlier this year, FMCSA, in its own study to Congress, concluded the costs of injuries and fatalities arising from crashes far exceed the minimum insurance levels interstate operators are required to carry. Additionally. the American Federation of Labor and Congress of Industrial Organizations (AFL-CIO) has noted the minimum insurance requirements have languished for decades and need to be improved.

In this Advanced Notice of Proposed Rulemaking (ANPRM), the FMCSA has asked 26 questions to commenters,...


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Wednesday, August 21, 2013

Changes to California Insurance Don’t Help

Today's post was shared by WCBlog and comes from www.lawyersandsettlements.com

Changes to California Insurance Don’t Help
By  Fresno, CA:

A California woman whose life has been described as “a living hell” blames the insurance underwriter, in association with her former employer, for leaving her high and dry with
denied disability insurance for the past eight years. Injured on the job in 2003, she was only paid benefits for two years. In spite of substantial evidence as to the woman’s disability, the insurer stopped payments, resulting in job loss and homelessness.

Guadalupe Ortega even had her children taken away from her, according to The Fresno Bee (8/6/13).

Ortega’s denied ERISA disability story is heart-wrenching. The one-time employee of Lyons Magnus of Fresno was injured on the job about 10 years ago, suffering injuries to her shoulder, neck and back. Her employer acknowledged that Ortega’s injuries were work-related and occurred on the job. Doctors having examined Ortega concur that the woman is 70 percent disabled.

Friday, May 13, 2011

Court Orders Workers Compensation Insurance Carrier to Comply With OSHA Subpoena

The workers’ compensation insurance company, who provided coverage to an employer where a double fatality occurred when a grain elevator exploded, has been order by a US Federal Court Judge, to comply with a subpoena issued by The Occupational Safety and Health Administration [OSHA] directed to obtain information about the safety of the facility. The opinion entered by Judge Philip G. Reinhard, adopts the report and recommendation of the magistrate judge, requires that custodian of records of the workers’ compensation insurance company testify and present documents concerning inspections and reports it prepared as to the employer, Haasbach LLC.


The Court reasoned that OSHA had the authority under Federal law to conduct inspections and investigation including requesting attendance and testimony of witnesses. 29 U.S.C. 657(b). The Court also held that OSHA’s request for loss control reports for 4 years prior to the accident were reasonably related to the investigation. The workers’ compensation insurance company will also be required to produce: site safety inspections, applications for insurance coverage for the site, and correspondence between the insurance carrier, Grinnell Mutual Reinsurance Co., and the the employer, Hassbach, concerning the site.

OSHA had issued 25 citations ($555,000 penalty) to the Illinois grain elevator operator, Haasbach LLC, following an investigation into the deaths of two young workers, Wyatt Whitebread and Alex Pacas (ages 14 and 19 years old, respectively), at the company’s grain elevator in Mount Carroll, Illinois. A third worker was injured at the time of the accident, when they were “walking down the corn” to make it flow while while machinery used for evacuating the grain was running.

Grain entrapments kill workers. All employers, especially those in high-hazard industries, must prevent workers from being hurt or killed as a result of recognized hazards,” said Assistant Secretary of Labor for Occupational Safety and Health Dr. David Michaels. “There is absolutely no excuse for any worker to be killed in this type of incident.”

OSHA Assistant Secretary Dr. David Michaels praised the decision. “The court affirmed OSHA’s authority to obtain relevant information from an employer’s workers’ compensation insurance company. This is not surprising legally, but it does illustrate that workers’ compensation and OSHA are not separate worlds divorced from each other,” he said. “Workers’ compensation loss control activities overlap with OSHA’s efforts to bring about safe and healthful workplaces, and in order to achieve a safe and healthful working environment for all Americans, all efforts of business, insurance, labor and government must move forward together.”

Judge Reinhard held that disclosure of the information into the public domain was permissible unless a federally recognized attorney-client privilege existed due to a pending state court action. If such a privilege was to be asserted as to certain materials that would be required to be produced, then the parties may submit a privilege log to the magistrate judge for consideration.

Solis v. Grinnell Mut. Reinsurance Co., 2011 WL 1642534 (N.D. Ill) Decided May 2, 2011
Related articles

· OSHA Anniversary April 21, 2011 10:00am C-Span Event (workers-compensation.blogspot.com)

· OSHA To Fine Employers for Distracted Driving Accidents (workers-compensation.blogspot.com)

· Video of The History of US OSHA (workers-compensation.blogspot.com)

· OSHA at 40 (workers-compensation.blogspot.com)

· US OSHA Warns Workers of Brazilian Blowout Formaldehyde Hazards (workers-compensation.blogspot.com)

Friday, October 8, 2021

OSHA cites insurance agency for exposing workers to coronavirus

A federal workplace health investigation found that an auto insurance company ignored coronavirus safety requirements and allowed others displaying symptoms to work at the exact Denver location where an employee died with COVID-19.

Monday, February 21, 2011

Obama Care for All

Over half our injured worker clients do not have health insurance. Many work for employers who do not provide health insurance, and they simply cannot afford private insurance on meager wages.

Since workers do not have group health insurance coverage, they are denied access to the medical care they need when their injury claims are denied by the worker's compensation insurer. And their claims are routinely denied based on the comp carrier's "hired gun" adverse medical examiner or reviewer. Understandably, hospitals and doctors, who have "bottom line" issues to face, will not provide treatment without some assurance of "upfront" payment, leaving injured workers in the lurch.

Wisconsin injured workers are fortunate that our State law provides a potential remedy for "prospective treatment"; a judge can order a worker's compensation insurance company to pay for treatment (including diagnostic testing, surgery, etc.). But the time lapse in waiting for a hearing (40-6 months) and inevitable insurance company appeal (another potential 6-8 months), realistically means that necessary treatment goes wanting. Injured workers without some insurance alternative to workers compensation suffer while waiting for treatment. Universal health insurance coverage provides an answer to this dilemma.

Thomas M. Domer practices in Milwaukee, Wisconsin (www.domerlaw.com). He has authored and edited several publications including the legal treatise Wisconsin Workers' Compensation Law (West) and  he is the Editor of the national publication, Workers' First Watch. Tom is past chair of the Workers' Compensation Section of the American Association for Justice.  He is a charter Fellow in the College of Workers' Compensation Lawyers. He co-authors the nationally recognized Wisconsin Workers' Compensation Experts Blog.