The Collision of Medicine and Insurance

Well over 90 percent of medical care in California is delivered to consumers by major HMO’s which have been deemed by the courts to be engaged in the business of insurance (i.e., Aetna, Blue Shield, Blue Cross, Cigna, Health Net and Kaiser). Every day, thousands of claims for medical care by insureds are reviewed for so-called “medical necessity” determinations. Those decisions are being made by medical personnel who oftentimes have no training whatsoever in the insurance claims handling standards in California or the covenant of good faith and fair dealing. They frequently ignore well-established California Supreme Court authority that requires that insurance policy language be construed liberally so that uncertainties about the reasonableness of medical treatment will be resolved in favor of coverage. This program will explore the issues and handling of bad faith cases which emerge.