By: Chris Aguiar, Esq.
Google “average words spoken per day” and you might see some interesting entries – such as, men use 7,000 words a day on average, as compared to women’s 20,000. When deciding what to write about today – it struck me that so much of my day handling issues on behalf of the benefit plans I represent have to do with words; which ones are used, the context in which they are used, and what they mean. When having discussions with the Phia Team, we always find ourselves asking, “what does that mean”? That’s because so much of the law, especially in health plan law, rests on just how clear the terms of the Plan are. It’s important that everyone be on the same page. When someone uses the word “normal”, everyone thinks they know what that means – but in reality, it means something slightly different to everyone. Norms are subjective, so use of the word isn’t necessarily sending the same message universally. When viewed that way, of course there are misunderstandings.
This whole line of thinking stemmed from a subrogation investigation I was involved in a few weeks ago. Interestingly, it wasn’t on behalf of a client - I was involved in it for my sister. My sister fell down the stairs at home and sprained her ankle– and of course, she received an accident questionnaire; naturally, she called me and the following conversation ensued:
… Cell phone rings …
Sister: Hi Chris, I got a letter from my insurance company asking about my ankle. Isn’t this what you do for a living?
Me: Yes, it is. What do you need?
Sister: Why are they asking me this?
Me: … Gives long detailed explanation about subrogation and why the insurance company would be asking this question… (Omitted in the interests of brevity)
Sister: I don’t want to deal with this, what do I do?
Me: Put that you fell at home and let’s see if they ask any more questions.
As it turns out, the insurance company didn’t ask any more questions. You might be thinking, “of course they didn’t, Chris – your sister fell at home”. Well, that’s only partly true. See, to my sister she was “home” but as far as the insurance company is concerned, she wasn’t. That’s because my sister doesn’t own her home – she lives in the 2nd floor walk-up apartment owned by my immigrant parents. Technically, she could bring a claim against my parents and as we know, so could the insurance company. See “home” is another word on a list of words I call “words with no meaning.” “Home” is where you lay your head at night, but depending on the context in which it’s being used – it isn’t necessarily something you own, and that has implications on a subrogation investigation.
But I knew what any good subrogation investigator knows – and that is that most of the time, the insurance company will get an accident letter that reads “fell at home” and they close the investigation without further research. It may not have been a lot of money, but for my immigrant parents, it was a headache I didn’t want them to have to deal with, and it was definitely a lost recovery opportunity for the insurance company. If you just take the words that people say at face value, you may misunderstand what they actually mean because the fact of the matter is, you have a different idea in your head of what was meant when they used certain words. Whether it’s in your everyday conversations or in the terms of an employee benefit plan – make sure you say what you mean and you mean what you say. Prepare yourself properly for a subrogation accident questionnaire. In your day to day life, it most often leads to minor misunderstandings and maybe some hurt feelings, but in the world of health benefits, it could lead to lengthy legal disputes and significant losses in Plan assets.
By: Brady Bizarro, Esq.
After the surprising collapse of the American Health Care Act (“AHCA”), House Speaker Paul Ryan (R-Wis.) remarked, “We’re going to be living with Obamacare for the foreseeable future.” Tom Price, the Secretary of Health and Human Services, proclaimed that Obamacare was “the law of the land.” In the immediate aftermath of the stunning political defeat, many political analysts concluded that the effort to repeal and replace Obamacare was finished. Only a few days later, however, there were talks of reviving the legislation over the next few weeks. The President himself took to social media to proclaim, “We are all going to make a deal on health care . . . that’s such an easy one.”
What changed? Republican leaders faced immense pressure from conservative activists, interest groups, the insurance lobby, donors, and constituents to follow through on one of their most significant campaign promises. In addition, the President has targeted individual congressmen, mostly from the House Freedom Caucus, and pressured them to get on board with the AHCA. Whatever the Republicans decide to do, they need to act fast. The legislative calendar is jam-packed with other top priorities, including passing a budget and tackling tax reform. Additionally, insurers are developing premiums and benefit packages for health plans to offer in 2018, and these will need to be reviewed by federal and state officials over the summer.
In the immediate future, despite the legislative failure, the Trump Administration still has plenty of ways it can cripple the ACA. The President himself has said the law would “explode” on its own, but that process could certainly be accelerated. For example, the Administration could block funding for ACA subsidies, refuse to enforce the individual and employer mandates, and redefine Essential Health Benefits (“EHBs”).
That last part, redefining EHBs, could have a significant impact on employer-sponsored health insurance. In fact, a new bill is in the works, and one of its provisions (included by the Freedom Caucus) is to repeal EHBs entirely. Essential Health Benefits are requirements that insurers have to cover services like maternity care, mental health care, and hospitalization. According to Republican lawmakers, removing these requirements would significantly lower the cost of certain health plans because they would not be forced to cover a defined list of services.
We will continue to follow new developments closely, especially those that impact employer-sponsored health care.
Contact The Phia Group today about an affordable care act external review!