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Caution: Having Health Insurance Doesn’t Always Protect You
Having insurance brings peace of mind. You don’t need to worry about getting sick or being injured. Until that is, the insurance company denies your claims. At that point, your peace of mind can quickly become a nightmare.

6 Reasons Health Insurance Companies Deny Claims

If your health claims are denied, your first step is to try to understand the reason for the denial. Here are the most common reasons an insurer denies a health care claim:
1. The procedure or drug is considered experimental or “medically necessary”
2. The cost of the treatment is greater than the limits of the policy
3. The treatment, drug or procedure was not pre-authorized
4. The treatment or procedure was specifically not covered by the policy
5. The claim was from a provider not covered by the policy, often called a “non-network” provider
6. The claim was not submitted in a timely way
Your doctor, hospital or the insurance company itself should be able to explain the reasoning behind the denial. Be sure to ask for their reasoning in writing.
Remember, however, explaining a denial does not mean the action was correct. Once you know why the insurer denied your claim, you can develop a strategy for appealing the denial. All insurance contracts include options for appealing negative decisions.

Appealing a Health Insurance Claim Denial

Sometimes, a denied health insurance claim is simply the result of a filing error by the provider. Asking the doctor, clinic, or hospital to correct and refile the claim may take care of the problem. In most cases, you should be prepared for a fight.
Here are the three main steps to pursuing an appeal of denied insurance benefits:
1. Send the company notice (writing a letter or using company-approved forms) of your intent to appeal. That should be sent within 180 days after your claim was denied. Give the company information about the claim you are appealing and why you think the denial was incorrect. Keep copies of everything related to the claim and appeal, including the explanation of benefits (EOB). If you have a phone conversation related to your claim, record the other person’s name and title. Take notes during the conversation.
2. If the company denies your appeal, you have the right to have your claim reviewed by a third party known as an IRO (Independent Review Organization). The insurance company must pay for the review and abide by the decision of the IRO. You must receive a determination within 20 days (five days for emergencies).
3. Consider filing a bad faith insurance lawsuit against the insurance company. Consult a lawyer with experience in bad faith insurance claims to determine whether you have a case. An insurance company may be guilty of bad faith if it refused to accept evidence from you or your provider, substituted its own evidence, failed to investigate, or delayed its decision. Be sure to bring all the paperwork related to your claim to your initial meeting with the attorney.
Denied by Your Health Insurance Company? Lean on a Lawyer for Help.

Contact our lawyers for help if your health insurance company wrongly denied your claim. Our experienced bad faith insurance lawyers can advise you about your rights and options.
January 20, 2018
Top 5 Tactics Used by Insurers to Avoid Paying Claims
Despite the marketing they do to make you think that they care, many insurance companies will use every trick in the book to delay paying your claim. In fact, some of America’s biggest and most well-known insurance companies regularly and purposely delay payments, deny claims with for no legitimate reason, and even wait for policyholders to die so that they don’t have to pay claims.

It is important to become familiar with these age-old, delay-and-denial tactics, so you can identify if and when your insurer is using them against you in your own claim.

5 Common Tactics Adjusters Use to Avoid Paying Out on Insurance Claims

Here are some of the most common tactics insurance adjusters use to delay or outright deny paying on your insurance claim:
1. Denial: Denying claims is one of the easiest and fastest ways for insurance companies to boost their bottom line. The practice of “just say no” to claims is seemingly ingrained in some insurance companies’ culture.
2. Discriminate by credit score: Few people realize that your credit score affects your insurability, what you pay for insurance premiums and can even prevent you from obtaining insurance altogether.
3. Delay and obstruct claims until the claimant gives up or dies: For many policyholders who purchased long-term care insurance, getting the insurance company to pay has been a nightmare. Customers report having to call insurance companies multiple times and resending documents multiple times. Companies then say that you filed your claim too late and will deny the claim, knowing that the policyholder will either give up and go away or is old and frail and will die soon.
4. Retroactively cancel policies: Obamacare effectively prevents insurance companies from denying coverage based on preexisting conditions. Now, some insurance scour coverage applications and medical records to find insignificant inconsistencies, claiming application fraud and then cancelling coverage.
5. Cancel policyholders for simply making a call about a claim: Learning that making a call about a claim might put them in a worse situation surprises most policyholders. If you have a claim for property damage, but decide to pay for the damage yourself, the insurance company may treat your inquiry as a claim and try to cancel your coverage.
This Really Is a Case of David vs. Goliath

The insurance industry in the U.S. has amassed assets worth trillions of dollars and pays its CEOs more than almost any other industry. One big reason they can accumulate so much wealth is because they cut back on or completely deny payments to their policyholders. The reason for this is simple: a lone policyholder has an uphill battle facing a corporate insurance company. That is why it becomes so important for individuals to seek legal help when dealing with insurance companies.

If You’re Getting the Run-Around From Your Insurance Company, We Can Help

Contact us for help filing for the benefits you deserve from your insurance company. We have years of experience helping people who have a rightful claim to their policy benefits.
January 5, 2018
How to Handle Talks With Insurance Adjusters After a Car Accident
You will get a call from your insurance company or the other driver’s company after a car accident. When you speak with the insurance adjuster(s), be very cautious. The adjusters can use anything you say to delay, deny or complicate your claim.
Insurance companies are in business to make money. They do this by paying out as little as possible on policyholder claims. Knowing this, it is best to prepare yourself for any conversation you have with insurance adjusters by taking the advice below.

Speak With a Lawyer First

Our first words of advice would be to contact an attorney after a car accident, before talking with anyone from an insurance company. Your lawyer can help you understand your options and help you frame your talking points before you ever get on the phone with an adjuster.

Say as Little as Possible to the Adjuster

A friendly adjuster will try to act like he or she is on your side. In reality, the adjuster is trying to make sure the company pays as little as possible. Here’s what to do and not to do if you end up talking to an adjuster:
- Never admit that you did anything to cause the accident. Hire a lawyer as soon as possible because the insurance company must call your lawyer. They cannot contact you if an attorney already represents you.
- Don’t ever say that you are “not hurt.” Because of the state of shock you’re in after an accident, you may not even feel your injuries until several days later. Most traumatic injuries become increasingly serious after a few days pass. You’ll obviously know if you have broken bones, hit your head or are bleeding. Soft tissue injuries are not as visible but can be clearly and permanently painful.
- Don’t discuss your medical condition at all. You can talk about vehicle damage but leave the medical discussion to your lawyer. You can state whether anyone in your vehicle was hurt and that they are receiving treatment.
- Ask whether the adjuster is recording the conversation. If the adjuster asks you how the accident happened, tell him or her to look at the police report. Do not consent to a recorded conversation with the other driver’s insurance company—ever.
- Don’t admit that you were listening to the radio, on your phone, or eating while driving. An adjuster may try to rush or pressure you into admitting that your phone or the radio distracted you.
- Never agree to let the insurance company order your medical records. They may try to get you to sign a release to order medical records. Only allow your attorney to obtain your records or gather them yourself after your medical treatment is stable or finished.
An adjuster will try to pin even the smallest amount of fault on you, as fault can significantly affect the outcome of your case, i.e. they save money and you lose benefits.

Contact Us Before Talking with Your Insurance Company or the Other Driver’s Company

If you unavoidably get stuck talking to an adjuster, keep your answers to a minimum and stop talking. And be sure to call a lawyer as soon as possible after your accident. The sooner an attorney is involved, the better your rights can be protected.
December 15, 2017
Federal Compliance in the Wake of Natural Disasters
After what seems like an endless stream of storms and natural disasters from one coast to the other, federal agencies are relaxing compliance and enforcement rules while everyone catches their breath. Title V of a new law, H.R. 3823, Pub. L. 115-63 covers emergency use of retirement funds by individuals and businesses affected by Hurricanes Harvey, Irma and Maria. Here’s how several federal agencies are responding.

Relief Authorized by the IRS

Current IRS rules and regulations limit the reasons for early withdrawals and loans from retirement plans such as 401(k) plans. The recent changes make it easier to obtain hardship distributions and loans for hurricane victims. They will now have access to their retirement accounts for emergency funds for themselves or to assist a child, parent, grandparent, or other dependent living or working in one of the affected areas.

Also, the law allows sponsors of single-employer defined benefit plans some extra time to make fund contributions and to file the required notices. The IRS has moved up the contribution deadline to January 31, 2018, for Texas and Florida employers affected by hurricanes Harvey and Irma. They’ve done the same for the deadline for filing the required, actuarial certification of the funded status and IRS Form 5500.

Relief Authorized by the DOL

The Department of Labor also regulates pension and health plans. It has offered up some relief for hurricane victims and employers, especially when filing benefit claims and COBRA extensions.
- Even if your place of employment has closed because of the hurricane, you are still covered under the employer’s health plan. If you are required to make a contribution payment, call the plan administrator to find out where to make the payment.
- If it is impossible to contact your plan administrator at your employer’s office, contact 1-866-444-3272 to speak to a DOL benefits advisor.
- If you think you may lose your health care coverage because of the hurricane, you may have other options:
  - Consider requesting special enrollment in your spouse’s plan within 30 days of losing eligibility of your main coverage.
  - COBRA continuation coverage
  - Individual health coverage
  - Health insurance through a government program at HealthCare.gov
- Ask your former employer, if it has closed because of hurricane damage, whether your retiree benefits may be affected.
The DOL notes that the guiding principle for employers must be to act prudently and in the best interest of the workers and families. Employees and their families rely on these insurance plans to maintain their health and well-being. Plan administrators and fiduciaries should make “reasonable accommodations” to prevent families from losing their health insurance coverage and other benefits in hurricane-affected locations if they are unable to comply with time frames and payment deadlines.

Additionally, if employers can’t make their contributions on time because of the hurricanes, they won’t be penalized if they live in the hurricane-impacted areas. Employers also won’t be penalized for failing to file timely notices of blackout periods. A blackout period is when an employer restricts an employee’s ability to manage or direct their own investments or obtain a loan or distribution from their fund.

Relief Offered by the PBGC

The Pension Benefit Guaranty Corporation (PBGC) was created by the Employee Retirement Income Security Act of 1974 (ERISA). The PBGC is an independent government agency designed to help the providers of voluntary, private pension plans remain viable and collects premiums from defined benefit plans. The PBGC is waiving plan insurance premium penalties, but not interest charges on late payments, from plan sponsors in Florida and Puerto Rico. Sponsors can make premium payments through January 31, 2018 without incurring a penalty.

The PBGC has extended deadlines in Florida and Texas for reporting plan terminations, reportable events notices and annual employer reporting.

Be Certain to Remain in Compliance

Several agencies have acknowledged the breath and scope of the recent natural disasters and the effect they’ve had on ERISA compliance across the board. The Department of Labor notes that benefit plan administrators, employers service providers, and employees especially may not be able to comply with the rules for processing claims and other benefits. Employees can also reference the FAQ recently released by DOL.

If you have questions about whether recent rule changes affect your plans and benefits, we can help you sort through the various deadlines and procedures. Contact us to set up a consultation and review of plan requirements.
October 10, 2017
The power of a paper trail in a landlord-tenant lease
Leases of property in Texas, such as a house or apartment, are very common. When problems arise and either party is unhappy, a landlord-tenant issue may head to court. When that happens, a tenant will want pre-existing proofs of what the arrangement was, to support his or her claim.

Like other contracts, the Texas Property Code states that an enforceable lease in Texas can be oral or written. The law provides for various default duties of landlords and remedies of tenant. Oftentimes, the parties can agree to change some of the default rules of the landlord-tenant.

To change these statutory standards, there must often be a writing to that effect. Typically, both the landlord and the tenant will sign the writing to give it affect. Some examples of changes that should be in writing include the following:
- Expanding the duties of the landlord with regard to security devices or smoke alarms
- Requiring tenant to pay for certain damages to doors, windows and screens
- Requiring tenant to pay for certain damages caused by doors or windows left open
- Waiving a tenant’s right to trial by jury
- Charging a reconnection fee in an electricity shut off situation
As noted by the Texas Young Lawyers Association and the State Bar of Texas, tenants can protect themselves if they have a written lease with the owner from the start. However, even in an oral lease, often a tenant will want a subsequent understanding or arrangement to be in writing. For instance, there are times when Texas requires a property owner to provide repairs within the rented dwelling as a matter of law.

The basic duty to repair certain items need not be in a written lease to be the tenant’s enforceable right. However, certain procedures must take place to trigger that duty to repair with regard to a specific item. A tenant must give a landlord notice that an item needs repair.

Verbally advising a landlord can cause a tenant problems later if the landlord fails to repair. It is difficult to prove that a conversation about repairs took place at all if one party denies it. It is more effective to put the request to repair in writing. Ideally, the tenant will send the dated writing by certified mail, return receipt requested via the United States Postal Service.

There are many steps a tenant can take as a matter of course to ensure that if there are problems with the landlord down the road, the tenant has proofs beyond mere allegations of what transpired. Putting things in writing, dated, is one of the most basic of habits a tenant can practice.
August 30, 2017
Understanding depreciation and cost of damage

When Texas residents incur property damage, they may naturally assume that their insurance company will cover the damage. What people may not realize, though, is that they are responsible for determining the cost of the damage their property has incurred. It is important for people to understand the idea of depreciation and how it affects their property.

In order to estimate the cost of property damage, people typically need to establish what has sustained damage. According to State Farm, people should inspect both the outside and inside of their house and put together a list of the items which are damaged. When homeowners create this list, it is recommended that they include information such as how much an item cost, how old it is and where they bought it, as well as list model numbers and brand names.

In order to be reimbursed for replacing damaged property, homeowners need to understand both the value of their property as well as how this value has changed. United Policyholders says that wear and age can cause your property to decrease in value, and this decrease is called depreciation. Although people might like the idea of set rates of value and depreciation, the process usually does not work like this. Instead, homeowners and their insurance companies can sometimes have different ideas about how much something has depreciated. This can be important because an insurance company may consider some depreciation to be excessive, and this affects the amount people receive after replacing their property.

Because homeowners play a large role in determining cost of damage, it is important for them to understand that an item’s age does not always affect the value. Instead, people should consider how much use an object has experienced. If homeowners feel that their insurance company is disregarding their estimations of value, they may want to speak to an outside party.

August 25, 2017
College students and renting: 4 things parents should know
If your child is preparing to head off to college in the coming weeks, he or she is not the only one feeling some pressure and excitement. As a parent of a college, you also have a lot to think about and worry about, whether your child is going to school in the same city or moving across the country.

One concern you may have is where your child is going to live. Many students live off-campus in apartments or rental houses. This allows them much more freedom and independence than if they lived on campus, but it comes with some important responsibilities of which parents should also be aware.
1. Whoever signs the lease is ultimately responsible for payment. In many cases, parents sign or co-sign a lease for their child, which means that if your child and/or his or her roommates do not pay rent, you could be on the hook for payment.
2. A property can be too good to be true. Property owners in college towns know how to appeal to students. However, if the amenities and offers that attract young renters seem too good to be a true, a parent would be wise to investigate.
3. The lease is a legal document. Make no mistake about it: a lease is a legal document. Once you or your child signs it, you (or they) are agreeing to the terms set in that document. Make sure you read it thoroughly and address any questionable terms.
4. Issues can arise with the security deposit. A landlord might wrongfully withhold the deposit or take the money and run off without your child getting the property. To avoid this, make sure you do some research into the property owner, ask a lot of questions and again, read the lease and terms of the security deposit thoroughly.
As a parent, your children’s safety and well-being is likely your top priority when they are away at school. Ensuring they have a good place to live and are not being scammed or cheated out of money is a responsibility you should take seriously.

If a dispute does arise between the landlord and you or your child, it is important to take that seriously as well. Working with an attorney to protect your rights and resolve the matter fairly can be in your best interests.
August 10, 2017
Why landlords do not return security deposits

To move into an apartment, you often must give your landlord a security deposit. After all, the landlord feels safer renting out property if he or she has money ready to deal with extensive damage.

However, tenants do not always get their security deposits back. Here is a look at some reasons why:

Tenant behaviors

Sometimes, landlords do not give security deposits back due to tenant behaviors such as not paying the final month’s rent (wanting to use the security deposit in lieu of that instead) or giving insufficient move-out notice as the lease requires. The landlord also might not return the deposit due to severe damage to the property.

No matter the case, though, the landlord is legally obligated to list the reasons why and to return the deposit or any leftover money within 30 days of the tenant moving out.

Disagreements on “normal wear and tear”

A landlord should not withhold a security deposit due to normal wear and tear. Basically, this is damage that would have happened no matter who was living in the apartment. For example, worn carpeting (assuming it did not come from constant, large parties) is normal wear and tear, while stained carpeting is generally not. Damage caused by storms and the like to the interior of the apartment generally does not fall under normal wear and tear.

However, there is enough gray area in “normal wear and tear” for it to come up often in landlord-tenant disputes. Tenants can protect themselves by taking pictures of the apartment before move in and right before move out. They should also ask their landlord to go through the apartment with them before they move out so they can discuss any possible issues of contention while the tenant is still around.

Shady business practices

And then there are some landlords who simply withhold security deposits and count on tenants not noticing or not caring enough to press the matter. These landlords are acting unethically, and this, unfortunately, happens more often than it should.

August 3, 2017
Know your rights if your HOA crosses a line
Being a part of a Homeowners’ Association can come with several benefits. You may have less to worry about in terms of maintenance and neighborhood disputes, and there may be many amenities you would not have access to if you lived outside an association.

However, HOAs are not perfect and an association’s rules can cross the line between protecting members and creating unnecessary restrictions. Below, we examine some examples of what an HOA can and cannot do, as well as what you can do if you wind up involved in a dispute.

Generally speaking, an HOA can place restrictions and limits on things like:
- The color you paint your house
- Your landscaping
- Any item you place on your lawn, including fences
- Whether you can operate a business from inside your home
- Noise levels
- Pets
- Parking restrictions
Things that HOA rules generally cannot do include:
- Violate fair housing laws
- Enforce overly restrictive terms
- Discriminate against certain homeowners
There can also be concerns with any terms that are difficult to enforce, arbitrary or subjective.

In most cases, the line between enforceable rules and unenforceable rules is clear. And you can choose not to purchase a home in a specific HOA if there are any rules with which you may not agree when you are looking to buy a home.

However, things can get much more confusing when the rules change over time or when they are enforced unevenly. Under these circumstances, it can be critical for a homeowner facing penalties for violations to speak with an attorney to understand their rights.

When HOA rules or decisions cost you money or prevent you from full enjoyment of your home, it may take legal action to protect these things. HOAs have authority and some abuse this position, which puts homeowners at a disadvantage in the event of a dispute. With the help of an attorney, you can level the playing field and fight back against unfair or unenforceable rules.
August 1, 2017
Drowning isn’t the only hazard associated with swimming pools

Whether you have a pool in your backyard or just take a dip when you stay in hotels with pools, you should be aware of the many risks associated swimming pools. Too often, people think that the risks stop and start with drowning, but the fact is that there are many other types of injuries or illnesses caused by an unsafe pool.

For instance, recently nine people were diagnosed with Legionnaire’s disease after staying in the same hotel.

Legionnaire’s disease is an illness that can be contracted by breathing in contaminated water. According to tests of the hotel’s swimming pool and hot tub, both tested positive for the harmful bacteria.

In most cases, victims who contract this illness are able to recover with the help of antibiotics. However, it can prove to be deadly to people who already have a compromised immunity system or suffer from other medical conditions.

Legionnaire’s disease is just one type of illness that can be caused from contaminated, poorly maintained pools. Others include cryptosporidium and various infections. Owners of hotels, gyms, apartment complexes and other properties with pools are expected to take certain steps to minimize the spread of these and other illnesses, but too often, a property owner will cut corners or ignore this obligation, and victims pay the price.

If you or a loved one developed a serious illness after swimming in a contaminated pool, then you may want to examine your legal options. Certain illnesses can prove to be devastating and take a considerable toll on a victim’s well-being. If you are sick, you could require hospitalization and various treatments, which can have a detrimental impact on your health, your job and your finances.

Under these circumstances, you could decide to hold the negligent property owner accountable for damages you have suffered. With legal guidance and support, you can build your case and take action against the appropriate party to secure the compensation you deserve.

July 27, 2017