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In Florida, and elsewhere, health insurance policyholders are entitled to appeal adverse determinations by their insurer — such as a denial of coverage — and thereby request that the insurer conduct a full review of their original decision. The appeals process is the first of several steps in challenging the determination made by your health insurer.  After you have exhausted the internal appeals process, you can move forward with an external, third-party review of the insurer’s decision, submit a complaint with a Florida state agency (such as the Florida Agency for Health Care Administration), or bring an action against your insurer (thus precipitating litigation). Even if you’re not sure whether you’d like to file a lawsuit against the insurer and pursue litigation in the Florida courts, it’s worth consulting with an experienced Miami health insurance lawyer to help guide you through the appeals process.  Depending on the circumstances surrounding the denial of your health insurance claim, you may be able to persuade the insurer to accept your claim. The Appeals Process in Florida So, how does the appeals process work? When you file a claim, you’re essentially requesting that your health insurer cover (and therefore reimburse) the costs of treatment.  If your insurer denies your claim, however, then that qualifies as an adverse determination, which you are entitled to challenge pursuant to the appeals process. Every insurer tends to have somewhat different grievance and appeals procedures (though they all must comply with state and federal regulation).  For example, some Florida […]

In Florida, insurers have a duty of good faith that they must adhere to.  Simply put, insurers must act fairly, honestly, and with due regard towards the interests of their policyholders.  If they fail to do so — for example, by wrongfully denying a claim, unreasonably delaying the handling of a claim, or otherwise interfering with the policyholder’s ability to recover the damages to which they are entitled — then they may be held liable pursuant to Florida bad faith insurance law. Bad faith disputes can be multi-layered and complicated.  In order to prove that the defendant-insurer has committed bad faith, you’ll have to show that they acted unfairly or dishonestly, or that they acted without due regard to your interests.  This is a “holistic” determination that depends on the total circumstances surrounding your claim.  You’ll have to prove that — given the circumstances — the insurer violated their duty of good faith.  Doing so is not always easy, but our Miami bad faith insurance lawyers are here to help. The insurer will almost certainly fight tooth-and-nail to avoid bad faith liability.  When you bring a bad faith claim, in Florida or elsewhere, the insurer will expose the weak points in your arguments.  For example, an insurer might argue that the circumstances justified a delay to give them time to investigate the insurance claim further, given that there was not sufficient evidence in the original submission for them to determine whether to payout. Potential Weaknesses to Avoid When Bringing Your […]

Usually, property loss does not involve exclusive damage to the dwelling unit itself — there may also be damage to other, non-dwelling structures (such as a fence around the property), or more commonly, to items of personal property that also reside within the dwelling.  In some cases, the personal property of the policyholder may be of significant value, and as such, their loss may expose the policyholder to unexpected financial vulnerability. For example, suppose that you own a number of antiques of significant value.  You intend to sell them to help pay for your child’s college tuition fees.  One day, however, a fire destroys much of your home, and the antiques are damaged beyond repair.  Their value is lost in an instant.  If the insurer does not provide adequate coverage that accounts for the losses you sustained due to the damage to your personal property, then you could be left in a very challenging financial position. If you have valuable personal property, it’s therefore critical that you consult with an experienced Miami property insurance lawyer for guidance. Duty to Cover Losses Sustained Personal Property In Florida, insurance companies providing homeowner’s insurance must grant policyholders coverage for their personal property, though limits on such recovery are frequently written into the policy to minimize the insurer’s eventual liabilities. It’s worth noting that Florida law requires insurers to give a policyholder the option to exclude their personal property from coverage (so long as the policyholder gives a formal, written statement of intent).  Excluding […]

As a general rule, insurers will act to avoid or otherwise minimize their liabilities under their insurance contract with a policyholder.  Sometimes, however, the actions taken by an insurer clearly violate their duty of good faith, and thus give the policyholder an opportunity to sue and recover damages pursuant to a bad faith claim.  Actions giving rise to bad faith claims include those that involve unreasonable delays in handling, resolving, and processing an insurance claim submitted by the policyholder. Bad faith claims can be somewhat confusing for those who are unfamiliar with the push-and-pull typical of many insurance disputes — as such, you’ll likely want professional guidance to help you navigate the challenges and complexities of bad faith litigation.  Get in touch with a qualified Miami bad faith insurance lawyer for assistance. Insurers Have a General Duty to Act in Good Faith In Florida, insurance companies owe a general duty of good faith towards their policyholders.  Essentially, the duty of good faith requires that the insurer act fairly and honestly towards one of their policyholders, with due regard of the interests of the policyholder.  In determining whether the insurer acted in bad faith, Florida courts must consider the totality of the circumstances surrounding the unreasonable delay at-issue. Suppose, for example, that you have submitted a claim, but the insurer continues to delay their decision on whether they will pay.  After investigating further, your attorney discovers that the insurer did not properly investigate and evaluate your insurance claim, and further, that […]

As a business owner, CGL insurance coverage is fundamental to effectively running your business in a highly-litigious society.  When a improperly mopped floor can result in hundreds of thousands of dollars, or even millions, in potential liability to injured third-parties, the value of CGL insurance skyrockets — CGL insurance provides the “peace of mind” necessary for a business to successfully operate. This reliance on CGL insurance can lead to challenging situations when the insurer wrongfully denies a legitimate insurance claim, or otherwise fails to step in and adhere to their duties under the contract.  Businesses facing millions in potential liability are put in an exceedingly vulnerable position, and insurers often take advantage of this power dynamic to undervalue claims and deny coverage.  Fortunately, Florida law entitles CGL policyholders to sue and recover damages on the basis of bad faith. Consider the following. Wrongful Denial In Florida, bad faith requires that insurers conduct a reasonable investigation of the facts surrounding the insurance claim at-issue, that the insurer not misrepresent the extent and nature of coverage, and that the insurer not wrongfully deny a legitimate insurance claim (i.e., without reasonable justification for such denial).  If your CGL insurance claim has been wrongfully denied, and you can prove that the defendant-insurer did not have reasonable justification for the denial, you could potentially recover damages for bad faith. Failure to Defend CGL insurance requires that the insurer step in and defend you in the event that an injured third-party makes a claim against you […]

Short term disability insurance benefits serve as a form of temporary wage replacement for those who are suffering from a serious disability (though it’s worth noting that not all plans require employment, or a history of employment, to qualify for disability benefits).  If you have been seriously injured in a car accident, for example, to such and extent that you can no longer work for a period of time following the accident, then your short term disability insurance will kick in and you will be entitled to receive benefits. Many people unfamiliar with disability insurance do not understand what short term disability insurance is, and whether they can actually receive benefits pursuant to their policy.  There is a real and unfortunate “knowledge gap” when it comes to short term disability, particularly in scenarios where the policyholder may be automatically covered under an employer-based group plan. In reality, short term disability insurance is fairly straightforward to understand.  Consider the basics. Short Term Disability Benefits Short term disability benefits payout when you have been injured, or are suffering from an illness or condition that is severe enough to disable you — in other words, enough to prevent you from fully and adequately handling your job/career duties for a specified time period (up to one year, usually).  Benefits vary depending on the insurance plan, and sometimes, on the nature of the work that you are involved in.  Some plans pay a percentage of your wages, while other plans pay a set amount of […]

If you are challenging the wrongful denial of your property insurance claim, the insurer is likely to assert that the language in the insurance contract is rather ambiguous, and that it should be interpreted in a manner that favors them. For example, suppose that your property insurance contract includes various provisions that exclude lightning damage from coverage.  A tree near your house is hit by lightning, which results in a fire.  The fire then spreads to your house, causing it to burn down.  Would you be entitled to make a property insurance claim, given the exclusionary provision at-issue?  The insurer is likely to argue no.  On the other hand, the provision is rather ambiguous with regard to the chain of causation.  It could be argued that the damage was not directly caused by the lightning, but instead by fire, which is covered. Ambiguity has often been used by insurers to entice policyholders into signing, only later to be construed in a manner that retracts coverage, thus minimizing the potential liabilities for the insurer.  Fortunately, Florida case law favors policyholders in the interpretation of ambiguous policy language.  Let’s take a quick look. Ambiguous Property Insurance Provisions Must Be Construed in Favor of Coverage In Florida, ambiguous provisions — where true ambiguity exists — of an insurance policy must be liberally construed in favor of the policyholder (coverage), and strictly construed against the insurer.  As the policyholder, this is highly protective and is likely to benefit you when it comes to litigation […]

Insurers — whether in the health insurance context, or some other context — will look for any possible justification to support their denial of a policyholder’s substantial claims, however legitimate those claims may be.  Recent scandals plaguing health insurers have shaken the industry to its core and revealed that many health insurers do not enforce their guidelines or properly supervise their assessors, which can lead to systemic wrongdoing. If you have a legitimate health insurance claim that has been denied by your insurer, you may be entitled to damages on the basis of their wrongful denial.  With the assistance of a qualified health insurance attorney, you can gather additional evidence and repackage your health insurance claim, appeal the denial, or — ultimately — pursue trial litigation against the insurer to recover the compensation to which you are entitled. Understanding the reasoning that insurers use to rationalize their claim denial is fundamentally important, as it highlights those issues that must be circumvented or challenged.  Consider the following. Common Justifications for Claim Denial Treatment Not Medically Necessary Whether treatment is deemed medically necessary depends on a number of factors, from the language and provisions of the insurance policy, to the circumstances of your injury (and potential treatment thereof).  Each plan may differ in terms of its definition of medically necessary treatment, with some plans executing a broader construction, and some plans executing a stricter construction.  For example, your plan may require that only certain type of medical devices be use to treat […]

Property insurance policyholders have an obligation to mitigate their losses whether they’re in Florida or any other jurisdiction.  Failure to mitigate such losses can have a myriad negative consequences for the would-be claimant, up to and including a relinquishment of reimbursement rights under the insurance contract.  As such, if you have suffered various property losses for which you are entitled to be paid out, it’s important to consult with an experienced property insurance attorney as soon as is practicable — your attorney will help you identify the steps you can take to ensure that you have expended reasonable mitigation efforts, and that you remain qualified to make a claim for such property losses (pursuant to your coverage plan). Mitigation Basics All property insurance policyholders have a duty to mitigate their losses in the wake of some adverse event that causes covered losses.  Though the specific obligations imposed upon the policyholder may differ from plan to plan, as a general rule, policyholders are expected to make reasonable efforts to mitigate losses to the extent possible. Reasonable mitigation efforts do not require that you exert unlimited efforts in order to prevent further losses.  What is deemed “reasonable” will depend largely on the circumstances.  Exposing yourself to significant harm is not required, nor is the exertion of effort that may confound your abilities. For example, suppose that a tree has fallen onto your house during hurricane-force winds.  Substantial damage has been caused to your house.  When the tree fell, however, an additional nearby […]

In Florida — and in other jurisdictions throughout the country — many health insurance claims are denied on the basis of the insurer evaluating the treatment that their policyholder received as “medically unnecessary” or “medically inappropriate” given the circumstances of the injury or condition.  Despite the fact that most insurers view the claims filed by their policyholders as little more than a nuisance, the gritty reality is that a denial can be life-changing.  Denial of one’s legitimate health insurance claims can lead to significant financial stresses, and even bankruptcy. If you have been subjected to a wrongful denial of your health insurance claim, then it’s important that you get in contact with an experienced Florida health insurance attorney as soon as possible.  You have the right to appeal the denial of your claims, and — potentially — to sue and recover damages pursuant to litigation, if the denial was wrongful.  Contact Ver Ploeg & Marino, P.A. to connect with a skilled health insurance attorney today. What is Medically Necessary? If your claim has been denied on the basis of it not being medically necessary, then you are likely wondering what constitutes “necessity” in the health insurance context.  There is no universal definition of medical necessity.  Generally speaking, each health insurance coverage plan defines “medically necessary” differently. For example, suppose that you suffer serious injuries in a motor vehicle accident and you have to get your leg partially re-constructed using metal scaffolding.  There are a variety of different brands, types, and […]