Plain language mandated for Insurance EOC’s Evidence of Coverage – Policy

Introduction to EOC Evidence of Coverage

So many questions are answered right in the Full Policy the evidence of coverage – EOC, in

• PLAIN English, as mandated by law.
• Along with your duty to read the policy!

Sure beats reading the law and then trying to see for sure if the law applies to you.   When you have your actual EOC, a couple of  easy ways to find stuff in the policy is the bookmarks, table of contents and the search feature.

The Evidence of Coverage (EOC) is a document that describes in detail the health care benefits covered by the health plan. It provides documentation of what that plan covers and how it works, including how much you pay. The EOC can also refer to a certificate or contract provided to a health plan member that contains information about coverage and other rights.  ^{National Disability Rights} *

Here’s where to find your  EOC Evidence of Coverage for:

• Individual & Family Plans
  • Sample EOC 2024 Blue Shield PPO
• Employer Group Plans
  • Sample 
• Medi-Cal
  • HMO – Managed Care Providers follow the links to get EOC
• Medicare Advantage Co Ordination Plan –
  • Medicare & Medi-Cal
• Email us if you are in CA and have any questions.

Must #read your policy

A court “must hold the insured bound by clear and conspicuous provisions in the policy even if evidence suggests that the insured did not read or understand them.”

• property casualty 360.com/is-there-a-duty-to-read-insurance-contracts
• IRMI duty to read
• Is there a duty to read?  Hastings College of Law
• Fordham Law Review Duty to read a changing concept 1974
• Kenny & Sams Law Firm 

The Hadlands, having failed to read the policy and having accepted it without objection, cannot be heard to complain it was not what they expected. Their reliance on representations about what they were getting for their money was unjustified as a matter of law.^{Sarchett v. Blue Shield of California (1987) 43 Cal.3d 1, 15, 233 Cal.Rptr. 76, 729 P.2d 267}

Hadland v. NN Investors Life Ins. Co. (1994) 24 Cal.App.4th 1578 , 30 Cal.Rptr.2d 88(Findlaw.com requires free registration)

STORY of what happened in this lawsuit

In the fall of 1985, the Hadland’s were notified of a 10 percent increase in the premiums for their health insurance under a policy with Reliance Standard Life Insurance Company. The Reliance major medical policy paid 80 percent of medical and hospital expenses, subject to a $250 deductible. The Hadland’s began to look for less expensive coverage. When they received a mailing from NASE describing low-cost group hospital insurance available to NASE members through NN, they sent in a postcard asking for further information. Kevin Winn, associated with NASE, NN and United Group Association (UGA) (a company that markets NN insurance), contacted the Hadland’s and, on December 5, came to their place of business to make a sales presentation. According to the Hadland’s, Winn told them coverage under the NN policy was “as good if not better” than coverage under the Reliance policy, at half the premium cost. Promotional materials described the policy as offering major hospital benefits. The Hadland’s joined NASE and applied for NN coverage. As it turned out, the NN policy was, as Winn had stated, half as expensive as the Reliance policy, but it did not cover most outpatient medical expenses. Moreover, NN’s benefits were paid according to a maximum benefit schedule which, in some cases, covered less than 50 percent of the actual charge for a surgical procedure. For instance, the maximum surgical benefit available under the policy was $6,000, regardless of the actual cost, and the maximum hospital room and board benefit for nonintensive care was $300 a day.

In January 1986, the Hadland’s received a certificate of insurance indicating their coverage benefits under the NASE group policy. In an attached letter, they were asked to read the certificate and call the NN office if they had any questions. The first page of the certificate advised them that if the policy did not meet their needs, they could return it within 10 days for a full refund. fn. 1 NN sent the Hadland’s a second letter to confirm their receipt of the certificate and to ask them to contact the insurer if they had any questions concerning coverage. The Hadland’s did not read the insurance contract. In November, Mary Jane Hadland was hospitalized for a surgical procedure. She incurred nearly $26,000 in medical and hospital bills. NN paid less than one-half, which, the Hadland’s concede, was the total of benefits due under the policy.

To take their fraud cause of action to the jury, the Hadland’s had to prove not only defendants’ false representations, but their own justifiable reliance

‘A reasonable person will read the coverage provisions of an insurance policy to ascertain the scope of what is covered. [Citation.]’ … Generally the insured is ‘bound by clear and conspicuous provisions in the policy even if evidence suggests that the insured did not read or understand them.’

NN (NASE prior Insurance Company) policy’s schedule of benefits expressly provided, for instance: an entirely unambiguous maximum surgical benefit of $6,000, regardless of whether the surgery consisted of an organ transplant, a partial or radical mastectomy or the amputation of a toe; [FN12] a maximum nonintensive care hospital room and board benefit of $300 a day; and a maximum benefit of **95$300 a day for outpatient hospital charges. The Reliance (the company the Hadland’s had before NASE) policy provided unqualified benefits of 80 *1589 percent of covered expenses. Thus, any representations by defendants of “full protection” under the NN policy, or coverage “as good or better” as the Reliance policy, were patently at odds with the express provisions of the written contract. If the Hadland’s had read it, they would have discovered its limitations, rejected it, and continued to pay the higher premium for the increased security of Reliance’s more comprehensive coverage.

View Entire Case on Findlaw.com Hadland v. NN Investors Life Ins. Co.

 (NASE’s prior Carrier, as pointed out by UICI’s 4/6/2006 letter)  This case shows that one must read the ACTUAL policy and can’t rely on Agent’s statements or brochures.  There are some exceptions…  This doesn’t just apply to NASE, but to ANY Insurance Contract.  See attorney Keler.com for more explanation.

Plain Language – Read Policy THREE times

The

doctrine of privity in contract law

provides that a contract cannot confer rights or impose obligations arising under it on any person or agent except the parties to it.

The premise is that only parties to contracts should be able to sue to enforce their rights or claim damages as such. However, the doctrine has proven problematic due to its implications upon contracts made for the benefit of third parties who are unable to enforce the obligations of the contracting parties. en.wikipedia.org

 In tort law, a duty of care is a legal obligation imposed on an individual requiring that they adhere to a standard of reasonable care while performing any acts that could foreseeably harm others. It is the first element that must be established to proceed with an action in negligence. The plaintiff must be able to show a duty of care imposed by law which the defendant has breached. In turn, breaching a duty may subject an individual to liability in tort. The duty of care may be imposed by operation of law between individuals with no current direct relationship (familial or contractual or otherwise), but eventually become related in some manner, as defined by common law (meaning case law). wikipedia.org/

Elements

Major Insurance Company
 Asserting the #Wrong Answer!

I just let my contract go with a certain well know and respected Insurance Company, as their RSM Regional Sales Manager told me THREE times, that I couldn’t write a medi-gap plan for someone whose MAPD plan non renewed.  Even though  I emailed her the official proofs.   She even kept this up at a sales meeting and told the other agents there the same thing.

When my client complained as I suggested to the CA Department of Insurance, the Insurance Company denied responsibility as they said they never received an application.  They didn’t mention anything about telling their agent that he would be wasting his time sending it in.

Email chain available on request.  I have this posted as I’m mandated to report ethical issues.

Free Look Period #view FULL Policy – E O C (Evidence of Coverage) when you purchase Health Insurance and full return privileges’

California Insurance Code §10276.

Every individual accident and health policy or contract, except single premium nonrenewable policies or contracts, issued for delivery in this state on or after July 1, 1962, by an insurance company, nonprofit hospital service plan or medical service corporation, shall have printed thereon or attached thereto a notice stating that the person to whom the policy or contract is issued shall be permitted to return the policy or contract after its delivery to the purchaser and to have the premium paid refunded if, after examination of the policy or contract, the purchaser is not satisfied with it for any reason.

The period time set forth by the insurer, nonprofit hospital service plan or medical service corporation for return of the policy or contract shall be clearly stated on the notice and such period shall not be less than 10 days nor more than 30 days. The policyholder or purchaser may return the policy or contract to the insurer, plan or corporation at any time during the period specified in the notice. If a policyholder or purchaser pursuant to such notice, returns the policy or contract to the company or association at its home or branch office or to the agent through whom it was purchased, it shall be void from the beginning and the parties shall be in the same position as if no policy or contract had been issued.  ^{California Insurance Code §10276.} 

Check your evidence of coverage for the exact provisions!

Covered CA has a different Opinion.  IMHO they are in violation of law!

See  § 155.430  *   Termination of Exchange  enrollment or coverage  

(b)Termination events –

(1)Enrollee-initiated terminations.

(i) The Exchange must permit an enrollee to terminate his or her coverage or enrollment in a QHP through the Exchange, including as a result of the enrollee obtaining other minimum essential coverage. To the extent the enrollee has the right to terminate the coverage under applicable State laws, including “free look” cancellation laws, the enrollee may do so, in accordance with such laws.