Pasadena & Los Angeles Insurance Denial & Dispute Lawyer

Our insurance law practice helps individuals and businesses get the services, benefits and compensation that their insurance company promises to provide. We help policyholders with health, business, homeowners, general liability, long-term care, automobile and other types of insurance policies. Problems begin when your insurance company delays, denies or underpays your claim. Consequences can vary – from the inconvenient to the catastrophic.

Scott Glovsky spent the first phase of his career working for insurance companies. His job was defending large insurance companies against allegations that they improperly handled claims. He worked on many lawsuits, but did not enjoy defending these companies. The insurance companies used questionable reasons for denying, delaying and underpaying claims. He sympathized with policyholders and was moved by how their lives had been turned upside down.

In 1999, Scott Glovsky stopped representing insurance companies and started representing policyholders. The Law Offices of Scott Glovsky has litigated several cases in which insurance company denials led to death or would have resulted in the death of the insured had they not personally paid for the denied benefit. Over the years, we have helped thousands of insurance policyholders obtain treatments, coverage and reimbursement from California insurance companies.  These companies include the biggest names in insurance: Anthem Blue Cross, Blue Shield of California, Health Net, United, and other companies who provide insurance through the Covered California exchange.

Common examples of cases that we handle include health insurance companies refusing to provide medically necessary treatment, business insurers denying business loss claims, long term care insurance companies denying benefits to seniors, and automobile insurers attempting to underpay on serious injury accidents. As experienced trial attorneys, the Law Offices of Scott Glovsky are able to seek justice for their clients in ways that other firms cannot.

Pasadena & Los Angeles Health Insurance Denial & Health Insurance Dispute Lawyer

Health insurance companies routinely find loopholes in their policies to minimize payouts. Here is how they deny, delay and underpay.

Deny:

  • Denial because medical treatment or procedure is not covered, authorized, medically necessary, or is experimental.
  • Denial because treating medical provider is out of network or out of plan.
  • Denial because procedure is merely cosmetic.
  • Denial because policyholder misrepresented something in their original application.

Delay:

  • Never received the paperwork.
  • Waiting for an evaluation from a required party (i.e. medical professional).

Underpay: 

  • Offers to pay for a lower cost treatment or procedure.
  • Offers partial reimbursement.

DUTIES OF THE INSURANCE COMPANY

Below are some of the basic responsibilities of an insurance company owed to the insured. If they are broken, the insurance company is likely to face liability for the resulting damages.

Duty to Defend

This is a duty to defend the policyholder when a third party brings a claim. The insurance company must hire a lawyer at its own expense to represent the policyholder to provide a meaningful defense and pay for all of the litigation costs. This duty is very broad and extends to all claims potentially covered under the policy based on facts alleged or otherwise disclosed in the claim. The courts have held that a meaningful defense is one that includes all claims and does not allow an insurance company to parse claims.

Duty to Indemnify

Indemnity as written and specified in contracts is often confusing. However, the concept is simple and refers to the obligation of one party to pay for the loss incurred by another party. As a policyholder, if you are found liable to a third party for damages, the insurance company must pay the damages – at least up to the policy limits. In insurance parlance, such a payment is called indemnity.

Duty of Good Faith and Fair Dealing

The courts have found that the special relationship between an insurance company and a policyholder creates a duty of “good faith and fair dealing.” The courts have often referred to what a policyholder is really buying as “peace of mind.” To get this peace of mind, an insurance company must do what is right to protect the policyholder. When an insurance company does not do what is right, they may be acting in “bad faith.” This bad behavior triggers very severe penalties for an insurance company: specifically the possibility of punitive – punishment– damages for their actions.

Duty to Fairly & Quickly Manage Claims

In both first party and third party claims, the insurance company has the duty to fairly and promptly investigate the claim and provide the benefits of the policy including paying valid claims. These duties are governed by the insurance company’s duty of “good faith and fair dealing” and must be carried out with reasonable speed.

Duty to Disclose Conflicts

Many types of conflicts can occur in an insurance case and the insurance company must disclose such conflicts to the insured. The defending attorney must equally weigh the interest of both the insurance company and the policyholder. If there is a conflict, the defense attorney must disclose it to both. Many conflicts then require a separate attorney for the insured – paid for by the insurance company. This is called Cumis counsel.

One conflict that exists in most cases is the possibility of the defending lawyer using policy limits as the upside risk to the insurance company at the risk of hurting the policyholder. Amounts over the limit would be the responsibility of the insured. The insured wants the defending attorney to aggressively settle the claim within the limits of the policy. A conflict may occur if the defending attorney knows he has a good chance of losing, but tries to minimize the settlement by threatening to go to trial. The defending attorney may use this tactic to scare the plaintiff’s attorney – remember, many law firms are small and don’t have trial experience and cannot pursue long and costly lawsuits.

Another common conflict is when an insurer believes certain claims are not part of the policyholder’s coverage and issues a “reservation of rights” letter stating that the insurance company reserves its rights to later deny the claim should facts surface that prevent coverage. These are conflicts that result in the defense developing a strategy that hurts the insured based on how the claims in a case are addressed and defended. In California, when an insurance company issues a “reservation of rights” letter, it is often acknowledging a conflict that may allow the insured to elect to hire a separate attorney.

Duty to Hire Separate Lawyer or Cumis Counsel

When conflicts prevent the insured from getting a proper defense, the insurance company must hire and pay for a separate lawyer to defend the policyholder. This lawyer is known as a Cumis counsel – an attorney representing a defendant in a lawsuit when there is an insurance policy covering the claim, but there is a conflict of interest between the insurance company and the insured. A separate attorney can lead to a better defense for the insured. Despite conflicts occurring frequently, their disclosure is not. Nor is it common for Cumis counsel to be appointed. We have litigated numerous cases where Cumis counsel should have been appointed but was not. Insurance companies have had to pay damages caused by the failure to provide Cumis counsel.

Duty to Settle Within Insurance Policy Limits

Recent California law indicates that an insurer should make a good faith effort to settle a case within its own policy limits regardless of whether or not the other party demands such a settlement. Failure to do so can lead to “bad faith” by the insurance company.

We want to help – call us at 1-877-316-2093 or request a free consultation online.

What Rights Do You Have When An Insurance Company Breaks Its Duties?

If your insurance company breaches your insurance contract or acts in bad faith and you incur damages, you can sue and recover damages. The Law Offices of Scott Glovsky can help. If you have suffered damages because of your insurance company’s wrongful denial, call us at 1-877-316-2093, complete the form below or send us an inquiry form by clicking here. There is no cost for this initial consultation.

Insurance Bad Faith Explained – Los Angeles and Pasadena Insurance Bad Faith Lawyer

When an insurance company denies, delays or underpays your insurance claim for bad reasons, it commits an injustice and may have broken the law. Insurance companies have a duty referred to as the “implied covenant of good faith and fair dealing:” a duty which exists by operation of law in every insurance contract. If an insurance company breaches this covenant, the policyholder may sue the company on a tort claim (for bad faith) in addition to a standard breach of contract claim. Under tort law, the plaintiff may recover punishment/punitive damages – damages to deter wrongful conduct.

The specific duties of an insurance company vary by type of claim (“first party” or “third party”) and industry (health, property, life, etc.). Generally, an insurance company must have policies and procedures in place to review and pay claims. They must investigate claims, determine coverage and pay proper values. They must follow applicable laws and regulations. When they violate one or more of these, they may be acting in bad faith. The Law Offices of Scott Glovsky is based in the Pasadena and Los Angeles area but works with policyholders all over California ensuring that insurers pay for claims and provide the treatments and services that the policyholders need and deserve.