insurance

This is a stickup – give us all his money: the true story of young brain injured John T

1131698_IMG_1668.JPG-640x426

 

One of the hazards of driving while high, is that you become a very bad driver.  A year ago, Mr. H decided not to take my word for it.  He smoked some pot.  Went for a drive.  Creamed a car.  In the back of the car, right where he t-boned it, sat high school student John T.  And his doggie who was instantly killed.

But this isn’t the story of Mr. H.   Or  of his arrest.  It is the story of the other villain in this case.

To complete his circle of irresponsibility, Mr. H was uninsured.  John was horribly and permanently injured.  Amazingly, the insurance company for the car in which he was riding, decided to make things as right as it could.   It agreed to pay all of the coverage it had on the car.  What a good neighbor.

Enter Swedish Health Services. (You can start booing now).

John’s mom was a nurse at Swedish Medical Center.  Every month this mom paid money for premiums for health insurance through SHS.

SHS started out by doing what it had to do.  It paid his medical bills.  These amounted to hundreds of thousands of dollars.

SHS was told the car insurance company was going to compensate John for his injuries.  SHS said – we want all of it.  Every single last dime.  Fork it over.  Except 20% to be paid to the attorneys for getting it.

SHS cited the legal principle of subrogation.   http://fightsubro.com/  This concept, allows health insurers – if they choose – to stick up the people they insure.  So that’s what they decided to do:

“While we sympathize with Mr. T’s situation, the law requires us to administer the Plan in accordance with its terms.  The Plan provides for the payment of attorneys in the amount of 20% of recovery, but does not authorize a waiver of its subrogation rights.  The Plan will accept the (entire) settlement, less 20% for attorneys fees, as partial satisfaction of its lien.  Please note that this acceptance is not a waiver of the ZPlan’s right to collect the remainder of its subrogation lien int he event additional funds are awarded to Mr. T in connection with this accident.  Please make checks payable to First Choice Health.”

Upon receiving this letter, Anne sent me an email that said this:

“Karen: Please see letter from First Choice in response to our T subro lien reduction request.   This is an ERISA lien and they are _________ (noun).”

How would you fill in that blank.

Stay tuned for part 2 in this ongoing series.

Photo by Seattle Police Department of the t-boned vehicle

 

 

The woman with multiple personalities – a pro bono story

OLYMPUS DIGITAL CAMERA

OLYMPUS DIGITAL CAMERA

The thing about being a young associate is that you pretty much need to do what you’re told.

During my late 20s, Tom Chambers was the boss.  If he said Karen do it, I pretty much followed orders.  Take this deposition.  Argue that motion.  Find an expert.  Find a better expert.  Tom’s softly spoken non-negotiable instructions structured my time at Chambers Court.

One day Tom summons me to his real office.  The cubicle.  Hands me a file and tells me to deal with it.  It is a pro bono case.  For a woman whom we’ll call …hmmm…Sybil.  Yes, that will work.

Sybil has been turned down by her disability insurance company.  She had been working but lost her job due to a severe psychological disorder.  She had an insurance policy from work that provided coverage in the event of a medical disability.  In a shocking development – the insurance company claimed her illness was a pre-existing condition and cut off her benefits.

In fact this is not shocking.  It is just typical.

Tom has great compassion for Sybil.  Takes on her case.  Opens a file.  And hands it  to me.

Over the next many months I analyze insurance records, medical files and put Sybil’s story together.  I can’t tell you what she says or the details about her story because that is a no-no.

But I can tell you this.  She is no joke.

In order to get her story straight I have to talk to her.  A lot.   I have to learn every little detail about her history.  From the time of birth forward.  What makes her tick.  The good things.  The not so good things.  What has changed so that she is no longer able to work.  This is a rigorous process.   It’s how Tom wants things done.  And I aim to please.

Phone calls have to be abandoned.  This is because if I call, I can’t tell exactly whom I’m talking to.  You see, Sybil is also Sherry and Alice and Tracey and about a dozen other people.  Each person has not only a different perspective, but an entirely different history.   Not to mention style of dress. makeup and tone of voice.   In reading the psychiatrist’s records, I piece together how this came to be.  Can’t tell you the reason.  But if you think of something very bad and traumatic that will be close enough.  Poor Sybil.

This means, need Sybile to come see me.  In person.  Up close and real.  All dozen of her.  Until we have figured everything out.  After awhile I get the hang of things.  The strangeness has worn off.  Can usually figure out who has come to visit.  Even get the names straight.

Eventually Tom’s pro bono project ends well.  The insurance company gives up.  Sybile’s policy is honored.  And the White Knight rides off in search of the next person he can save.

Photo:  Alysha and Reid exhibiting their elvish personalities waiting for dinner with me, Shellie and Dan at Umi Saki House..

Where do these all powerful medical insurance adjusters come from?….

You get in a car wreck.  But fortunately have purchased Personal Injury Protection or Medical Pay insurance.  So you believe you are fully covered.  That is, until the adjuster cuts off your benefits.  Usually with the help of a “medical review” sometimes performed by an actual doctor (who never sees or talks to you). 

Where do these all powerful medical insurance adjusters come from.  These people who are deciding whether we get treatment or not.

Here’s a typical example:

                      8                      E X A M I N A T I O N

9   BY MS. KOEHLER:

16        Q.   Where do you work?

17        A.   Allstate Insurance.

18        Q.   How long have you worked there?

19        A.   Eleven years.  November will be 11 years.

20        Q.   What’s your job title?

21        A.   Claim adjuster.

22        Q.   What’s your other job titles you’ve had since

23   you’ve been at Allstate?

24        A.   Well, I’m currently a senior claim adjuster, and

25   it’s been just claim adjuster prior to that.

 

                                                                     5

1        Q.   How long have you been senior?

2        A.   I believe it’s been two years.

3        Q.   What were you hired on as?

4        A.   Claim adjuster.

5        Q.   What’s your educational background?

6        A.   I have a B.A. degree from the University of

7   Washington.

8        Q.   In what?

9        A.   Psychology.

10        Q.   What was the year?

11        A.   1987 I graduated.

12        Q.   Any jobs other than Allstate after graduation?

13        A.   Yeah.

14        Q.   What else?

15        A.   First job out of college I worked for Northwest

16   Center for the Retarded.

17        Q.   In what capacity?

18        A.   I was an instructor for them.  The developmentally

19   disabled adults came to Northwest Center to work, and so I

20   helped them with their work.

21        Q.   How long did you work there?

22        A.   Two years.

23        Q.   Anywhere else?

24        A.   Yeah.  After that, I worked for Cascade Savings

25   Bank.

 

                                                                     6

1        Q.   As what?

2        A.   I was an escrow assistant there.

3        Q.   For how long?

4        A.   I started out as a temp through Kelly Services for

5   maybe four months and then worked there two years.

6        Q.   Why did you leave Northwest Center for the

7   Retarded?

8        A.   I wanted to try something new and try to get some

9   better pay.

10        Q.   What did you do after Cascade Savings?

11        A.   I worked for North — or sorry — Western Title.

12        Q.   As what?

13        A.   I was a receptionist there, and I also moved on to

14   do reconveyances.

15        Q.   How long were you working there?

16        A.   A year.

17        Q.   And then where did you go?

18        A.   I worked at a daycare center.

19        Q.   As what?

20        A.   A three-through-five-year head teacher.

21        Q.   For how long?

22        A.   About six months.

23        Q.   What was the name of it?

24        A.   You know, I don’t recall.

25        Q.   Then what did you do?

 

                                                                     7

1        A.   I went on to Country Companies Insurance.

2        Q.   When was that?

3        A.   When was that?  Let’s see.  It was about 1995.

4        Q.   What was your initial position?

5        A.   I was an assistant receptionist.

6        Q.   Why did you take on that job?

7        A.   Why did I take it on?

8        Q.   Uh-huh.

9        A.   I had temped there through Kelly Services, and it

10   was a good opportunity for me.

11        Q.   How long did you work there?

12        A.   About two years.

13        Q.   What was your last position worked?

14        A.   At Country Companies I left as a receptionist.

15        Q.   Then where did you go?

16        A.   Allstate.

17        Q.   So you went from being a receptionist to a claim

18   adjuster?

19        A.   Yeah.  I did handle minor claims at Country

20   Companies.

21        Q.   What was your job title at Country Companies?

22        A.   They had me down as receptionist assistant.

23        Q.   So at Allstate you were hired on as a claims

24   adjuster?

25        A.   Yes.

 

                                                                     8

1        Q.   What year?

2        A.   1997.

3        Q.   What department?

4        A.   PIP.

5        Q.   Which office?

6        A.   Marysville.

7        Q.   Have you ever left the office?

8        A.   Yeah.  Yes.  I’m in the Bothell office now.

9        Q.   Since when?

10        A.   About six years ago.

11        Q.   Prior to adjusting claims, what courses did you

12   take in insurance claim-handling?

13        A.   In insurance claim-handling, we took courses like

14   introductory to medical reports, a lot of online courses,

15   basic claim-handling classes on interpreting policy.

16        Q.   When did you take these courses?

17        A.   After beginning at Allstate.

18        Q.   So the years would be 1997?

19        A.   Yeah, when I started.

20        Q.   Did you review documents involving claim core

21   process redesign, CCPRs?

22        A.   No.

23        Q.   Do you know what the courses that you were taking

24   on were based upon?  In other words, do you know how the

25   courses that you were taking were developed?

 

                                                                     9

1        A.   No.

2        Q.   Do you know any of the motivation surrounding any

3   of the courses that you took?

4        A.   No.

5        Q.   Were you told any of the policies and procedures

6   of Allstate at the time that you began working there other

7   than work through classes?

8        A.   Through classes?  No, just started out doing like

9   training on the computers and things like that.

10        Q.   Did you actually have a training period before you

11   began working?

12        A.   Yes.

13        Q.   Where were you trained?

14        A.   We did — in Marysville.

15        Q.   Did you ever leave the state for training outside

16   of Washington?

17        A.   Yes.

18        Q.   When did you do that?

19        A.   In June 1998.

20        Q.   Where did you go?

21        A.   To Northbrook, Illinois.

22        Q.   How long were you there?

23        A.   Two weeks.

24        Q.   Was that for claims school?

25        A.   Yes.

 

                                                                    10

1        Q.   Did your job title change after 1998?

2        A.   No.

3        Q.   Did you ever go back to Northbrook?

4        A.   No.

5        Q.   Did you ever go to California?

6        A.   No.

7        Q.   Did you ever go to any state outside of Washington

8   for training other than Northbrook in 1998 for two weeks?

9        A.   No.

10        Q.   All of the training that you had in Washington,

11   was it at Marysville?

12        A.   Yes.

13        Q.   And online; am I correct?

14        A.   Yes, and then sitting-alongs with other coworkers.

….

 

                                                                    18

3   What medical training have you had?

4        A.   None.

5        Q.   What science courses did you take in college?

6        A.   I took human anatomy, physics, chemistry, organic

7   chemistry.  I took two physics classes that I recall.

8        Q.   Have you ever worked in a medical office?

9        A.   I temped for two weeks at an x-ray department at

10   the University of Washington.

11        Q.   I take it you perform no medical treatment or

12   services?

13        A.   Correct.

14        Q.   It was a receptionist job or something like that?

15        A.   Orderly.

16        Q.   Do you claim that you have any medical training or

17   background?

18        A.   No.

 

And he lifted his arms to the sky and declared: you are healed!

dila-thumb-450x180-16719

If you are walking in a marked crosswalk with a pedestrian light on.  With friends.  And a guy in a Honda is talking on his cel and decides to turn left.  And mows you down.  The car strikes you.  You land on top of the hood and then fall down and strike the pavement.   And you are taken by ambulance to the hospital.  And end up bruised and hurting all over.  Then you my dear friend need to see Dr. Sean Ghidella.  Because according to him – you will be healed and back to normal within three months.  Boom.  Just like that.

That’s what he testifies to today in a binding insurance arbitration proceeding.  Under oath.

Now there is an exception.  If you have a pre-existing susceptibility to injury the three month rule won’t always apply.  But never fear.  It is highly doubtful you are alive if you suffer from the kind of pre-existing condition that Dr. G is talking about.

In this case, the 34 year old woman had scoliosis which is an abnormal curvature of the spine.  Some of us develop or are born with it.  We can be a bit out of whack because of it.  She also was having some spine discomfort due to a situation at work in the months leading up to being hit.  But was any of that a pre-condition that could have made it harder for her to heal.  No way.

Dr. G says – if you were on top of a building and fell eight (8) stories and had orthopedic injuries and survived – that would be a preexisting condition.

So the good news is the woman did not fall eight (8) stories before being hit by the car.  She should have healed in three months.

You know what a defense attorney does with that kind of testimony.  Um hum.  Attacks the woman’s credibility.  All of her injuries (after the magic three months) are due to something else.

Moral of the story:  if you are hit by a car and haven’t fallen eight (8) stories before hand, then go see Dr. G.  He will heal you in three months.  Boom.  Just like that.

Postscript:  The Arbitrator – Scott Holte – did not have quite as much faith in Dr. G as the defense.  In ruling for the plaintiff here is in part – what he said:  I do not find Dr. Ghidella’s report and testimony on the causation issue is persuasive.  Specifically I don’t find that Dr. Ghidella’s opinions have a sufficient factual foundation…

.

 

Deposition of a Squirmy Insurance Adjuster

The Ethel Adams case gained national attention when Farmers refused to provide insurance coverage.  It said the “car accident was not an accident” because the person whose truck hit hers, was the victim of a whacko’s road rage.  Public outcry and pressure from the Office of Insurance Commissioner caused Farmers to cave.   Paul Stritmatter and I then filed a bad faith lawsuit against Farmers

This snippet is from the deposition of one of the big wig insurance adjusters who handled Ethel’s case.    Tom Lether is the defense attorney objecting all the time.  Watch the adjuster (try to) explain the difference between good faith and bad faith. 


Check out a recent interview by Super Lawyers about my blog. Yes, I'm a lawyer. But I'm also a human being. I have a doggie named Nala, three daughters, eat brown sugar cinnamon pop tarts for breakfast, and wear jeans as often as possible when not in court.
Favorite Quotations

If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.
— Nelson Mandela


Be still when you have nothing to say; when genuine passion moves you, say what you've to say, and say it hot.
— D. H. Lawrence


Why slap them on the wrist with a feather when you can belt them over the head with a sledgehammer.
— Katharine Hepburn


Truth, when not sought after, rarely comes to light.
— Oliver Wendell Holmes, Sr.


Hold fast to dreams For if dreams die Life is a broken-winged bird That cannot fly.
— Langston Hughes


There is no charm equal to tenderness of heart.
— Jane Austen


Words have no power to impress the mind without the exquisite horror of their reality. — Edgar Allan Poe


If you just set out to be liked, you would be prepared to compromise on anything, wouldn't you, at any time? And you would achieve nothing! — Margaret Thatcher


Be who you are and say what you feel because those who mind don’t matter and those who matter don’t mind.
— Dr. Suess


Be sure you put your feet in the right place, then stand firm.
— Abraham Lincoln


If you are neutral in situations of injustice, you have chosen the side of the oppressor. — Desmond Tutu


True eloquence consists in saying all that is required and only what is required. — La Rochefoucauld


No act of kindness, no matter how small, is ever wasted. — Aesop


The thing you fear most has no power. Your fear of it is what has the power. Facing the truth really will set you free. — Oprah Winfrey


If you're not failing every now and again, it's a sign you're not doing anything very innovative. — Woody Allen


The soul never thinks without a picture. — Aristotle


To thine own self be true, and it must follow, as the night the day, thou canst not then be false to any man. — William Shakespeare


Float like a butterfly, sting like a bee. — Muhammad Ali


Intelligence is the ability to adapt to change. — Stephen Hawking


It is better to have less thunder in the mouth and more lightning in the hand. — Apache proverb


People take different roads seeking fulfillment and happiness. Just because they're not on your road doesn't mean they've gotten lost. — Dalai Lama


How wonderful it is that nobody need wait a single moment before starting to improve the world.
— Anne Frank


Learn to laugh; it is a discipline to be mastered. Let go of the everlasting burden of always needing to sound profound. — Richard J. Foster


Imagination is more important than knowledge. Knowledge is limited. Imagination encircles the world. — Albert Einstein


Believe, when you are most unhappy, that there is something for you to do in the world. So long as you can sweeten another’s pain, life is not in vain. — Helen Keller


Remember that lost time does not return. — Thomas á Kempis


If thou faint in the day of adversity thy strength is small. — Proverbs 24:10


Everybody gets so much information all day long that they lose their common sense. — Gertrude Stein


It is harder to crack a prejudice than an atom. — Albert Einstein


The right of trial by jury shall be preserved. — 7th Amendment of the U.S. Constitution


I'd rather die on my feet than live on my knees. — Ludacris


And the trouble is, if you don't risk anything, you risk even more.
— Erica Jong


Words are chameleons, which reflect the color of their environment. — Judge Learned Hand


You may shoot me with your words, You may cut me with your eyes, You may kill me with your hatefullness, But still, like air, I'll rise. — Maya Angelou


The moment that justice must be paid for by the victim of injustice it becomes itself injustice. — Benjamin Tucker


He who keeps his eye on results cannot give himself wholeheartedly to his task, however simple or complex that task may be. — Howard Thurman


An eye for an eye makes the whole world blind. — Mahatma Ghandi


Life is painting a picture, not doing a sum. — Oliver Wendell Holmes Jr


The truth does not change according to our ability to stomach it emotionally. — Flannery O'Connor


We must adjust to changing times and still hold to unchanging principles. — Jimmy Carter


To be rooted is perhaps the most important and least recognized need of the human soul. — Simone Weil


It is not the level of prosperity that makes for happiness but the kinship of heart to heart and the way we look at the world. — Alexander Solzhenitsyn


It is high time that the ideal of success should be replaced by the ideal of service. — Albert Einstein


The opposite of love is not hate, it’s indifference. The opposite of art is not ugliness, it’s indifference. And the opposite of life is not death, it’s indifference. — Elie Wiesel


I don’t know the key to success, but the key to failure is trying to please everybody. — Bill Cosby


The time is always right to do what is right. — Martin Luther King Jr.


I had rather attempt something great and fail, than to attempt nothing at all and succeed. — Robert Schuller


It is very easy to break down something. You can take a stone and throw it through that window; that is easy. Try fixing it, and that takes longer. It takes longer to help someone who has been broken. That’s the work you’re doing. — Desmond Tutu


How we spend our days is, of course, how we spend our lives. — Annie Dillard


Mine honor is my life; both grow in one; Take honor from me, and my life is done. — William Shakespeare


To straighten the crooked you must first do a harder thing – straighten yourself. — Buddha


A thought is an idea in transit. — Pythagoras


Fall seven times, stand up eight. — Old Japanese proverb


No generalization is wholly true, not even this one. — Oliver Wendell Holmes Jr.


Of what use is eloquence? He who engages in fluency of words to control men often finds himself hated by them. — Confucius


There is a vitality, a life-force, an energy, a quickening that is translated through you into action and because there is only one of you in all of time, this expression is unique. — Martha Graham