Health Insurance Companies May Be Under Paying Claims

What happens if you are traveling and have to visit a hospital or doctor? Or what happens if you need to see a local doctor immediately who may not be in your health insurance company's “approved network of doctors?” You would expect your health insurance company to pay a reasonable amount towards those bills, wouldn’t you? But that doesn’t always happen.

Recent cases from across the country indicate health insurance companies may be significantly under paying out-of-network claims. This means consumers are unfairly left to pay the balance of these charges. In a recent Federal case, California based Health Net Inc. agreed to repay $215 million to its customers for using an out dated and lower than reasonable payment schedule for out-of-network claims. The company also agreed to spend $40 million to update its claims processing protocol to avoid this problem in the future.

DO YOU THINK YOU’VE BEEN THE VICTIM OF AN UNDERPAYMENT FOR AN OUT-OF-NETWORK CLAIM? Please call us or e-mail us at mcw2@moore-wolfe.com and put “underpayment” in the subject line. You may be entitled to a refund.

State Farm Must Pay Victim

A Mobile County jury ruled against State Farm and in favor of their insured in a civil trial that concluded on January 7th. Moore & Wolfe attorneys, Steve Moore and Karlos Finley, represented Francilla Ridgeway during the two day trial. Ms. Ridgeway was the victim of a serious motor vehicle collision that occured on Novemebr 14, 2006 near Chickasaw. The collision occured as she moved into an intersection with a green light and was hit by an Alabama State Trooper vehicle that was involved in a high speed chase. The jury concluded after only about an hour and a half of deliberation that State Farm owed their insured $100,000.

The trooper was pursuing Daniel Keith Gibson who, just seconds before the collision, had gone through the intersection at over 90 miles per hour and was headed directly towards a school zone just a block away. Ms. Ridgeway testified at trial that she did not see or hear the approaching trooper vehicle. When pressed on cross examination by State Farm's attorney, Ms. Ridgeway said she was distracted by Gibson's vehicle and when her light turned green she moved into the intersection but was looking down the road in the direction of the fleeing vehicle. That afternoon, Gibson led law enforcement officers on a high speed chase through Mobile, Saraland and Chickasaw. He admitted to speeds in excess of 140 miles per hour and said he attempted to ellude police because he, "didn't want another speeding ticket."

State Farm, who provided underinsured motorist coverage to Ms. Ridgeway, never offered her any of those benefits under the policy, claiming Daniel Keith Gibson was not at-fault in causing the collision which left Ms. Ridgeway with over $24,000 in medical bills. They maintained this position even though Mr. Gibson's insurance carrier had earlier paid his policy limits to Ms. Ridgeway. "Underinsured motorist coverage is a safety net that you pay a premium for," explained Steve Moore. "If you are injured through the fault of someone else and they don't have enough insurance to cover all of your damages, then you can use your underinsured motorist coverage to make up the difference," he explained.

Besides incurring over $24,000 in medical expenses, Ms. Ridgeway lost almost $8,000 in wages as she recovered from shoulder surgery necessitated by the collision. At trial, State Farm said the accident was not the fault of Mr. Gibson but rather the fault of Ms. Ridgeway, in closing argument State Farm's attorney even implied that Ms. Ridgeway lied under oath when she said she was not on her cell phone at the time of the collision as he suggested maybe she was distracted by talking on her cell phone.

"For over two years State Farm has refused to pay the benefits owed under this policy by continuously blaming Ms. Ridgeway for this accident. She was an innocent victim of Mr. Gibson's idiotic decison to run from the police," said Moore in closing argument. Ms. Ridgeway is a single mother of four with her oldest son in college at the University of South Alabama. She testified that every month for years and years she struggled to pay her insurance premiums to State Farm, which she said were about $70 per month. "At her income level she had to work about 10 hours every month just to cover her premiums and this is what she gets for her hard work," her attorneys told jurors in closing argument referencing State Farm's blaming her for the collision.

For additional information on this story visit the Mobile Register online.

Innocent Victim of High Speed Chase has to sue her own Insurance Carrier for Benefits

The Mobile Press Register recently reported on an interesting case pending in Mobile County involving a State Farm insured who was an innocent victim of a high speed chase. On November 14, 2006 Francilla Ridgeway was injured when a State Trooper vehicle collided with her vehicle at an intersection in Chickasaw, AL. Ms. Ridgeway entered the intersection on a green light and did not see or hear the approaching Trooper vehicle. The Trooper was engaged in a high speed pursuit of a fleeing motorist who had led law enforcement on a 30-40 minute high speed chase throughout the Mobile, Saraland and Chickasaw area. The fleeing motorist, Daniel Gibson, was driving a highly modified Ford Focus and admitted to traveiling in excess of 140 miles per hour and driving recklessly as he attempted to evade the pursuing law enforcement officers.

Ms. Ridgeway originally named Gibson as a defendant in the civil action claiming his negligence or wantonness caused the collision with the Trooper vehicle. Mr Gibson's insurance company paid their liability limits but the amount was insufficient to cover the full extent of Ms. Ridgeway's injuries. Under her policy with State Farm, Ms. Ridgeway has "underinsured" motorist coverage which provides additional benefits if an at-fault driver does not have enough liability coverage. State Farm denied Ms. Ridgeway's claim and never offered any underinsured motorist benefits to her claiming the collision was not Mr. Gibson's fault but rather Ms. Ridgeway's fault for not seeing the oncoming Trooper even though she entered the intersection with a green light.

Steve Moore, Ms. Ridgeway's attorney said he elected not to sue the Trooper involved in the incident because he did not believe he did anything wrong. "While some people may look at this situation and say the Trooper should have backed off from the pursuit or maybe he should have gone through the red light at a slower speed, I just felt legally the person who should be accountable is the person who caused this situation to begin with and that is Daniel Gibson." State Farm "stands in the shoes" of Mr. Gibson for any damages he may legally owe Ms. Ridgeway per the terms and conditions of the underinsured motorist provisions of their policy with Ms. Ridgeway. "They do not want to pay benefits that Ms. Ridgeway paid a premium for so they argue that the accident wasn't Mr. Gibson's fault and have forced their insured to litigate this case," said Moore.

The Mobile Press Register online at al.com has more on this story.