health insurance

Georgia’s Insurance Commissioner Ralph Hudgens is going to set insurance companies straight- well, he can try, but likely will not succeed.The piece from the national healthcare reform puzzle which requires insurance companies to justify rate increases will become effective on September 1, 2011.If this change helped to hold down rates, then persons injured in car accidents could better afford the premiums while they are out of work trying to recover. Unfortunately, if you are injured in an auto accident, you are likely to see your health insurance premiums continue to rise. This could be resolved once the new healthcare law’s mandatory provisions take effect. However, as Georgia personal injury attorneys have warned, if the healthcare law is declared unconstitutional thereby eliminating universal coverage, the problem with personal injury victims getting the treatment they need while unable to work will continue indefinitely.

The rate justification requirement forces insurers to publically post any rate increases over 10% and explain why the increase is reasonable.This 10% rule only applies to policies covering individuals and small businesses.All new double-digit rate filings will be submitted with much more documentation now. It is then left to the state to decide if the increase is reasonable based on health care costs and other factors.

We are relying on this new rate review process to save us from the big, bad insurance company, right?Unfortunately, Georgia law ties the hands of the insurance commissioner’s office by giving him no authority to reject rates submitted by the insurers.The insurance commissioner’s office “enforces and regulates laws enacted by the state legislature under Title 33 of the Official Code of Georgia.”In other words, Georgians will have to rely on unreasonable rate hikes to be handled by the federal government.

In 2001, auto accident injury victims received what was thought to be good news from the U.S. Supreme Court in Great-West Life & Annuity Ins. Co. v. Knudson, 534 U.S. 204, 122 S.Ct. 708, 151 L.Ed.2d 635 (2002). In Knudson, the Plaintiff was injured in an auto accident. Her medical bills related to injuries sustained in the auto accident were paid by her ERISA health insurance plan. Upon settlement, the settlement proceeds were paid into a special needs trust. The Plaintiff’s ERISA plan attempted to obtain reimbursement directly from the Plaintiff for the medical bills the health insurance carrier paid for treatment related to the auto accident injuries. The Knudson Court ruled that the plan had no right to reimbursement since such payments would constitute enforcement of a legal remedy, something not allowed under ERISA.

However, through Sereboff v. Mid Atlantic Medical Services, 547 U.S. 1015, 126 S.Ct. 1869 (2006) and its progeny, the Supreme Court illuminated the fact that the Court will not interpret every plan as seeking a prohibited legal remedy. The Court will look to the plan language on a case by case basis to determine whether the plan creates an equitable remedy – specifically, whether a fund has been specifically identified by the plan language, and if so, to what part of the fund the plan will be entitled to recover reimbursement. The plan’s right to reimbursement will fail if the plan itself fails to create a lien by agreement, by “specifically identifyi[ng] a particular fund, distinct from [the plan beneficiaries’] general assets. . . and a particular share of that fund to which [the plan] was entitled.”

Articles Tagged with health insurance

Insurance Companies Held to a New Standard on Health Insurance Premiums? Not Exactly.

ERISA Health Insurance Issues in Auto Accident Injury Matters