Dan Veroff is an attorney with Merlin Law Group’s California practice. In addition to his expertise in property insurance, Dan has a wealth of knowledge and experience resolving disputed health, disability, and life insurance claims, individually and in class actions. When Dan joined Merlin Law Group in 2018 to help grow the firm’s California presence, Dan also started increasing the firm’s visibility in the health, disability, and life insurance sphere nationwide. Dan obtained his expertise in these areas prior to joining Merlin Law Group when he worked for one of the top California law firms in these practice areas.
Health insurance disputes are the most common, and that should not surprise anyone, both because of the volume of health insurance claims and the reputation of the health insurance industry. Health insurance claim disputes can be the most frightening to the policyholder, as they can hold up a lifesaving or pain-saving procedure or bankrupt one who already went through a procedure they believed was covered. Most of the denials that reach Merlin Law Group are based on an alleged lack of “medical necessity” – the concept that health insurance should only pay for what is truly needed and only after other, less invasive and expensive solutions that could work prove ineffective. Many health insurance claim denials based on medical necessity do not dispute the need for medical care at all; the companies typically argue that a lower level of care was needed. These disputes often underlie the larger battle between medical providers and health insurance companies over medical costs. But when the consumer is stuck in the middle of that battle, most of the time the consumer has already received the higher level of care and the lower level of care the insurer says was appropriate was never provided. Thus, the entire claim is denied. Suddenly, a bill the insurer would have paid based on negotiated rates for a third of the price comes to the insured at full cost, followed by collections agencies and eventually litigation. Indeed, medical providers are becoming far less agreeable to eat unpaid costs and are sticking consumers with the bills as another way to put pressure on health insurance industries to loosen up their practices. Health insurance claims are also denied for a variety of reasons, such as a provider being out-of-network for non-emergency care, failure to get pre-authorization for a service when required, or even a provider’s failure to input the correct medical billing codes.
Disability claims are different even though they also involve health. A disability insurance policy typically reimburses something lost – usually a salary or the ability to cover business overhead and similar items – in the event one, due to a disability, cannot perform the material and substantial duties of their occupation in the usual and customary way, or another occupation they are reasonably qualified to perform based on education, training, experience, and other factors. Most commonly, these policies pay two-thirds of pre-disability earnings, which can be calculated in a variety of ways, with offsets for other income such as social security benefits. The policies typically pay benefits monthly to age 65. Policies also provide partial and total disability benefits depending on the degree of disability. A disability claim dispute is handled differently depending on whether the insurance was obtained through a group plan, like an employer, versus an individual policy. Depending on which applies, the legal protections change substantially. Disability claim denials are typically also based on a medical judgment, where companies often have doctors review records or briefly examine insureds and then disagree with the opinions of the insured’s doctors. Depending on the policy and claim, an internal appeal may or may not be required before filing suit. Other disputes typically include determinations of the amount of benefits and offsets, eligibility for coverage, whether an exclusion or limitation applies for certain types of disabilities (often mental illness and alcohol or drug-related conditions).
Last but not least is life insurance. Life insurance also involves health, but the health of someone already deceased. Often, these disputes center around whether the insured misrepresented anything about their health on their insurance application. In many states, for example, if one dies within two years of the policy’s issuance, the insurer can investigate if there were any misrepresentations on the application, even if it did not do so before the death. If there are, the insurer can refund the premium and deny the claim. Other life insurance disputes include who is the correct beneficiary, the cause of death related to an exclusion or limitation, or even disputes when the insured is still alive, such as how premiums are calculated. Life insurance claims are also subject to different forums and rules for resolution depending on where the coverage was obtained. These are the same rules that also apply to disability insurance.
Since joining Merlin Law Group, Dan has worked with Merlin attorneys across many states to help them with their life, health, and disability disputes, such as California, Colorado, Florida, Texas, and more. Some examples of successful results include:
- Carrier denied in-patient mental health and substance abuse clinic for hallucinating and violent college student who was ordered to attend a lower program by the court, which he failed – substantial settlement well above amounts owed.
- Carrier terminated disability claim multiple times over several years and repeatedly miscalculated benefits owed for repeated organ failure patient – substantial settlement covering all past, present, and future disability benefits owed, attorney fees, and emotional distress.
- Carrier refused to pay for surgery to correct an incredibly painful broken jaw for several months – substantial settlement including all costs of procedure and attorney fees.
- Carrier denied disability claim contending that a severely disabled individual from multiple stabbings and motorcycle accidents could work full time – substantial settlement covering all past, present, and future disability benefits owed, attorney fees, and more.
- Carrier denied health insurance claim based on alcohol exclusion where insured did not consume alcohol until after the injury to help cope with the pain – full claim paid plus attorney fees.
- Carrier denied life insurance benefits to pastor diagnosed with lymphoma shortly after applying for life insurance – substantial settlement for surviving family.
- Carrier refused to pay for severe head trauma after patient injured during procedure for another covered claim – substantial settlement.
Should you need assistance with a health, disability, or life insurance claim, Merlin Law Group can assist.