by 50Cal20 on Mon Jul 22, 2013 7:02 am
Here is my list of typical delays or denials I have seen from excess insurance companies:
1. Refusal to reimburse expenditures for self-insured employer's failure to timely place them on notice of claim, even when there is not prejudice.
2. The excess insurance claims adjuster arbitrarily and unilaterally establishes a reduction of reimbursement (i.e., 50% reduction) for any reporting violation, including lack of supporting evidence.
3. Refusal to reimburse for failure to conduct utilization review even, if the services were obviously warranted.
4. Refusal to reimburse when the self-insured administrator overrides a UR decision and provided services, where in the long run money is saved (i.e., override UR and authorized x-rays that cost $100 rather than incur a $500 expense of going to an AME).
5. Refusing to contribute towards the cost of a structured settlement that buys out the excess insurer's liability. Example: Employee is entitled to $150,000 in PD of which $20,000 pierces the excess insurance level. However, the cost to voluntarily fund a structured settlement that pays $150,000 is only $120,000 resulting in a $10,000 savings to the employer and a $20,000 savings to the excess carrier. Yet the excess carrier refuses to contribute because the retention cap was not met.
The easiest way to resolve all these issues, as well as others, is to have a written agreement beforehand added to the insurance policy addressing these issues.