In this Blog category you will find articles about laws regarding claims and insurance policies . Personal Injury suits and insurance claims may require the help of an attorney. A good lawyer can protect your rights under the law.
A yearly investigation by Minneapolis station KARE11, followed by two recently filed class-action lawsuits, found that pharmacists must sign so-called “gag” clauses preventing them from disclosing lower prices than what patients with insurance were paying for medications. In most cases, an insurance co-pay for a medication was twice as expensive as for just paying cash for the same medicine.
Why Co-Pay More Expensive than Paying Cash?
Pharmacy Benefit Managers (PBMs), which serve as the middleman, set the price you pay the pharmacy for medications. In many cases, the price they set for your co-pay is twice the cash price. “Gag clauses” in the contracts pharmacists sign with PBMs prevent them from telling you this.
What Happens to the Extra Amount You Pay?
Instead of going to the pharmacy, as much as 80 percent of your more expensive co-pay is pocketed by Pharmacy Benefit Managers and insurance companies. UnitedHealth Group, which gets much of its revenue from its Pharmacy Benefit Management division, frequently uses the so-called “clawback tactic” to reap profits from sales of pharmaceuticals.
UnitedHealth Group Named in Two Class-Action Suits
In October 2016, two class-action lawsuits were filed accusing UnitedHealth Group of a “scheme to defraud” customers in connection with prescription copay pricing.
The lawsuits claim that UnitedHealth Group and its related companies used “gag clauses” to try to keep its so-called “clawback scheme” secret.
You Can Shop for Lowest Prices on Medicine
There is one drawback to paying cash for your prescriptions. The money you pay does not apply toward your deductible. If you want to pay cash, consumer advocates recommend shopping around. To search for the least expensive price for your prescriptions see Consumer Reports article with tips about finding the best prescription drug prices. You can also check prescription drug prices and find discount coupons at pharmacies in your area through GoodRX.com and Lowestmed.com.
There are an estimated 30 million Americans with diabetes. For the 6 million of them who rely on insulin, buying that medication is a life or death situation. So when the three major companies that make insulin in the US steadily ratchet up their prices, sometimes in lockstep, diabetic patients with high deductible insurance plans who pay out of pocket for their prescriptions struggle to get the lifesaving medication they need.
Most of the 30 million diabetic Americans have type-2 diabetes, meaning their body doesn’t use insulin the right way and may require a prescription for it if lifestyle and diet changes aren’t enough. The immune systems of the 10 percent of diabetics who are type-1 destroy the cells that release insulin, requiring a lifetime of daily treatment.
All Three Insulin Manufacturers Raise Prices
Since 2004, the manufacturer list price for insulin is up by triple digits. The three major companies that make insulin, Novo Nordisk, Eli Lilly, and Sanofi, have each increased their insulin prices from 380-400 percent, forcing individuals to pay thousands of dollars a year for the medicine they need; and when one company raises prices, others follow.
Sticker Shock for Those Who Pay Out of Pocket
While insulin prices have been steadily going up for years, most patients had a relatively small copay and didn’t see prices increase. Since the Affordable Care Act went into effect, employers seeking to cut labor costs, have steered their workers toward less expensive, high deductible health insurance plans forcing patients to pay out of pocket.
Why Are Insulin Prices Increasing?
Prices are set by pharmaceutical companies at whatever the market will bear. Pharmaceutical companies say that price increases are necessary to support research and development of new medicines, although they say they are working to lower prices by offering copay assistance programs for those without insurance. They say that pharmacy benefit managers (PBMs), such as CVS Caremark, have forced them to raise prices when they negotiate larger rebates for insurance companies (savings that patients paying list price with co-pay don’t see). PBMs say that pharmaceutical companies are responsible for setting prices and creating and managing the rebate program.
Generic Insulin Set to Hit Shelves December 2016
Unlike medications that can be chemically synthesized, until now there has been no generic (“biosimilar”) version of insulin, which is made from biologically altered yeast or bacteria. By
Oregonians with incomes over 138 percent of the federal poverty level who earn too much to qualify for expanded Medicaid, who are also without employer paid health insurance, are in a coverage gap.
New Federal Medicaid/Medicare Standards
In 2014, the Oregon Center for Public Policy estimated that about 120,000 Oregonians who must get health insurance or pay a fine would remain uninsured by 2019. Of that group, nearly half would be low-income people with incomes below 200 percent of the federal poverty line who earn too much to qualify for expanded Medicaid under the Oregon Health Plan.
Oregon is not the only state experiencing this coverage gap. To address the problem, in March 2014 the Center for Medicare and Medicaid Services (CMS) established standards for the Basic Health Program, allowing states to access federal funds to establish alternative subsidy programs for low-income individuals who don’t qualify for expanded Medicaid coverage.
In January 2016, New York State made an official request for certification of its Basic Health Program. In April of that same year, the state of Minnesota also applied for certification.
Oregon Presents Study Report to Legislature
In 2014, the US Department of Consumer and Business Services, in collaboration with the Oregon Health Authority (OHA), and in consultation with a stakeholder advisory group, presented its “Oregon Basic Health Program Study” report to the Legislature.
Once established, Oregon’s Basic Health Program would be an affordability program (IAP) offering coverage in place of Marketplace coverage at a much lower cost for those with incomes from 138 to 200 percent of the federal poverty level. Under this program, a three person household with a combined income of up to $40,180 would qualify for coverage. Similarly, a two person household earning up to $31,860 would qualify for coverage and a single person household earning up to $23,540 also would qualify.
The Basic Health Program established by the Affordable Care Act through the Center for Medicare and Medicaid Services (CMS) also provides an opportunity to expand coverage to those above 200 percent of the poverty level still uninsured and to offer more affordable premiums and cost-sharing for low-income residents.
Health insurance premiums through the exchanges are expected to rise by an average of 25% in 2017, with fewer health insurance plans available to choose from as health insurance companies continue to drop out of the exchanges.
About 75 percent of people enrolled in plans this year get subsidies to help pay their premiums, and those subsidies will go up along with premiums. However, those who make too much to qualify for subsidies because they earn more than 400 percent of the federal poverty level will pay the entire amount. For a family of four the threshold is $97,200 and for an individual it is $47,520.
Switching Health Plans with Dwindling Options
Those who see premium increases in 2017 and decide to switch to a less expensive plan with fewer benefits, will see a dwindling list of choices in many areas. An analysis by the consulting firm Avalere Health found that about one-third of U.S. counties, more than 1,000 counties in 26 states, will have only one health marketplace insurer next year. Another eight states will have only one participating insurer in a majority of counties. Healthcare.gov has taken steps to help consumers whose insurer is leaving by matching them to the closest comparable plan on the marketplace next year.
Why Are 2017 Premiums Increasing?
Due to financial losses from participating in the exchanges, insurers have either increased premiums or have decided to drop out. Facing a financial deficit of $430 million, Aetna has left the marketplace, and several others, including United Healthcare and Humana, have sharply scaled back their participation for next year.
Insurers have had to increase premiums because, they say, enrollment has brought in older sicker patients than was expected, and they can no longer deny coverage for pre-existing illnesses. Those younger and healthier who, it was hoped, would offset expenses incurred by sicker patients, are either covered under their parents’ plans or have decided to pay the non-enrollment penalty fee rather than participate in the exchanges.
The reinsurance plan within the Affordable Care Act that paid insurers who took on high cost patients they can no longer exclude, has not reduced insurance premiums by 10% as expected and expires this year, so insurers have raised premiums to cover its absence in 2017.
ACA Still a Bargain Compared to Before Plan Implemented
Although rate hikes for 2017 may seem excessive, Brookings Institute analysis concluded that, even after
In November of 2015, the Oregon Legislature passed a bill that sought to improve insurance benefits for victims who are injured in motor-vehicle collisions. Senate Bill 411 (SB 411), was signed into law by Governor Kate Brown. The bill expands coverage for two key areas of car insurance policies: personal injury protection (PIP) and under or uninsured motorist coverage (UIM).
Effective as of January 1, 2016, the new law provides injured parties greater access to compensation. Changes made by the law go into effect on policies renewed or created on January 1, 2016 or later. Drivers who renewed their policies before the specified date cannot benefit from the changes the law presents until it is time to renew again.
Personal Injury Protection
Oregon is one of the 15 states in the US that requires drivers to carry some form of personal injury protection, or PIP insurance coverage. The minimum coverage for PIP is $15,000. This means that in the event that you are injured your insurance company covers reasonable and necessary medical expenses worth up to $15,000 regardless of who was at fault. This coverage extends to cyclists and pedestrians who are hit by a motor vehicle.
Two Major Changes
Before SB 411, PIP insurance paid medical expenses incurred from an auto accident for up to a year after the collision occurred. Now that SB 411 has been enacted, the payment period increased to 2 years. Since $15,000 is nowhere near the average amount needed to recover from serious personal injury, and since the payment period grew a full year, it is possible to purchase additional coverage.
Another boon to injured parties that arose from SB 411 is the manner in which at-fault carriers must reimburse the PIP carrier. It used to be that the at-fault party’s insurance must reimburse the injured party’s insurance in full unless the injured party’s economic damages exceeded the amount recoverable. The injured party’s insurance company could still receive compensation even if not enough of it was available to fully cover the injured party.
Under the new law, the at-fault party’s insurance must pay the injured party after the injured party recovers all damages from his own policy. This leads to greater compensation for the injured party, as he or she can receive damages from both insurance providers. If your medical expenses exceed your insurance coverage, you can receive compensation
Yes, I’m a lawyer, but in a former life I was a YMCA boating instructor, camp counselor and life guard. In that context safety was front and center. Sadly, I have seen safety take a back to recreation as children become young adults… until tragedy strikes.
Memorial Day weekend will be here in a few days so NOW is a great time to remind all my friends and clients that “an ounce of prevention is worth a pound of cure.” Keep in mind that most safety rules were enacted in response to serious injury. Here I focus on Oregon boating safety rules, precautions and insurance.
1. Oregon Boating Safety Certificate
All persons operating a boat of 10 horsepower or more must take an Oregon approved boating safety course and carry a boating safety card. It only costs $10! The course is $25.50. Here is the link to get a boating safety card which does not expire. (Note a boating safety card is not a boating license). See ORS 830.086.
2. Drinking and Boating
Operating a boat while under the influence of any intoxicant is illegal. ORS 30.325. Also the owner of a boat is responsible for negligent operation of a boat just as an owner of an auto would be. ORS 30.330. Reckless operation of a boat is aslo prohibited in Oregon waters. ORS 30.315.
3. Boating Accidents
Oregon law requires boaters to promptly respond and report boating accidents. ORS 830.475. Also promptly report any boating accident to your boat insurer. If an accident happens, you must provide your NAME, ADDRESS, and BOAT ID # to all occupants of THE OTHER BOAT. In Oregon you must AID THOSE HURT by towing their boat to shore if needed and helping the injured get medical help. ORS 830.475. You must file a boat accident report for all boating accidents involving injury or property damage over $2k.
4. Boating Insurance
Your auto insurance probably only covers you when you are tailoring your boat. Purchase boating insurance to cover damage to your own boat as well as damage caused by your liability to others. Different types of boats (Ex. Wave runner v. sailboat v. motor boat). It’s best to purchase boating insurance from an agent who is knowledgeable about your boat and your exposures. Boating insurance, unlike Oregon auto insurance, does not require no fault medical insurance. Discuss the need for medical
“Ridesharing” services like Uber and Lyft are not about sharing. Make no mistake about it, Uber and Lyft are money making enterprises also commonly known as “businesses”. If you were injured in an auto accident as a passenger in a ridesharing vehicle or hit by a ride sharing car, you may be wondering what insurance applies, if any. Your concern is on point since most auto insurance policies issued to individuals and families contain an exclusion for driving for commercial purposes.
Sorting out whether a driver’s private or commercial (Uber, Lyft) auto insurance policy applies requires determining whether the driver was: 1.Off duty; 2. Available for hire; or 3. Picked up / En route to a pick up a paying passenger. When the driver, is off duty and not logged into the Ride share “app”, the driver’s personal insurance applies. When the driver is available for hire but has been paired with a potential passenger, both Uber and Lyft provide at least the state minimum coverage for bodily injury caused by the driver’s fault. (In Oregon, the minimum liability limit for injuries is $25k per person, $50k per accident and $15k for no fault medical coverage known as PIP.) As of March 2016, when a ride share driver is en route to a potential customer or already has a customer in his car, Uber and Lyft provide $1M in liability coverage and uninsured motorist coverage.
Very recently some insurers have begun offering new insurance products designed to fill the business exclusion coverage gap brought about by ride sharing. If you were in an injury accident involving an Uber driver, get a copy of your policy. Contact an experienced auto lawyer in to make appropriate claims on your behalf. Never give a statement to an opposing insurance adjuster or rideshare company before seeking legal counsel.
Oregon lawmakers recently passed Senate Bill 411 which provides Oregon motorists additional medical benefits and additional underinsured medical benefits. But, there is a catch. These additional coverages only apply to auto insurance policies issued or renewed in 2016 or later. If your policy was issued before then, contact your insurer or agent to request auto policy renewal.
1. ADDITIONAL YEAR OF AUTO “PIP” MEDICAL BENEFITS
Unlike neighboring states Washington and California, Oregon requires all auto insurance policies to contain a medical payment and wage loss benefit known as Personal Injury Protection, commonly referred to as “PIP”. Oregon law requires auto insurance policies to contain a PIP benefit of at least $15,000, for reasonable and necessary medical expenses related to an auto accident, regardless of fault. For policies issued before 2016 this benefit lasts for 1 year. For policies issued or renewed in 2016 later, this benefit last 2 years. Take away: RENEW ANY AUTO POLICY ISSUED BEFORE JANUARY 1, 2016 TO GET AN ADDITIONAL YEAR OF PIP MEDICAL BENEFITS!
Generally speaking, here’s how the PIP medical benefit works: If you are in an auto accident, your own insurer (or the insurer for the driver if you were a passenger) will front medicals charges to the extent of the PIP coverage you purchased (at least $15k). Your auto insurer will have a reimbursement claim against the driver at fault, which it usually resolves directly with the at fault insurer for the at claim conclusion. In this way, persons injured in an accident get some some medical costs paid without having to first win an argument about who was at fault.
In addition to this no fault medical benefit, Oregon PIP coverage also includes:
• A wage loss benefit of 70% of wages lost up to $3k per month for insured persons taken off work by a doctor for at least 14 consecutive days;
• A child care benefit of up to $25 per Day up to a max of $750 if the insured is a parent of a minor child who is hospitalized for more than 24 hours;
• Funeral expenses up to $5k;
• Loss of services of $30/day for up to 52 weeks for unemployed persons with at least 14 days of consecutive disability if those services are performed by a non-family member living outside the household.
2. OREGON UNDERINSURED (UIM) COVERAGE NOW STACKS
Oregon law also requires auto insurance issued in
This is the first post in my weekly blog series: Personal Injury Claim Value: Key Variables. During the past 25 years I have quantified claims big and small–as a large loss claims analyst (1996-2000), an insurance defense attorney (1990-1996) and since 2000 as a plaintiff personal injury attorney. I dedicate the series to my past clients, adversaries and their insurers whose now resolved disputes laid a pattern of lessons learned.
When it comes to personal injury claims ultimately there is really only one question: “How much is my claim worth?”
The short, quick answer is a simple number. A number answer is understandable, plentiful at cocktail parties and easily generated from online injury calculators. The downside to quick injury claim quantification is huge– quick quantification is usually wrong.
In reality, claim value depends on several key variables. Notice the word “variable”. Just a tiny variable tweak can bring huge differences. Hold that thought. Now consider this. Variables constantly change and differ from place to place. Jurisdictions differ; each fact pattern has nuisance. Thus, this blog series is potentially infinite.
To make sense of this mess, each blog post focuses on one key variable only. I start with the most important variable of all—YOU. Your injury claim is all about you, or more accurately perceptions about you. You are NOT the person you are perceived as.
Perception of YOU
You are a trustworthy, hardworking person who was seriously injured by someone else’s mistake. But you won’t get a dime if the decision maker (however unreasonable) sees you as a cheater, slacker or injury faker.
In the personal injury claim context, “who you are perceived as” is more important than who you really are. Mindfulness of other lenses of perception is crucial to successful injury claim resolution. The best you can, clear your mind of your point of view. Then ask yourself: “How might others view me, my injuries, my story my actions in the context of this injury claim?” Your honest answers will lead toward better decisions and more effective testimony.
Decision makers spontaneously and unconsciously pre-judge based on individual life experience, attitudes and beliefs. During jury selection jurors will reveal personal experiences. Listening carefully will provide useful clues to juror paradigms. To add a sour twist, some jurors consciously conceal true biases during jury selection. Your lawyer should ferret out potential jurors with life experiences that may cause prejudgment of you.
You will never know exactly how the decision maker perceives you. You
Richard Rizk is now admitted to the Washington State Bar. He is also licensed to practice law in Oregon, Federal Court (9th Circuit), Oregon District Court and Illinois (currently inactive). Mr. Rizk became familiar with Washington insurance laws as a high level claims analyst in the 1990s working to resolve environmental insurance coverage disputes involving insureds including Cadet Manufacturing, Port of Vancouver and Dairygold.