Appeals, complaints or grievances with an Insurance Company?

#Reasons for filing a Covered CA appeal

Your eligibility notice explains what you are eligible for and the programs for which you do not qualify. Depending on your eligibility results, you may appeal any of the following (check as many boxes as you would like):

• I was denied enrollment into a Covered California health plan
• The amount of Premium Assistance (tax credits that help pay my monthly premium) is not correct – Get Calculation
• The level of Cost Sharing Reduction (help paying my out of pocket expenses) is not correct
• I was denied eligibility for an exemption from the individual responsibility CA Mandate Penalty
• Covered California did not process my information in a timely manner
• Covered California stated that I am not a US Citizen or US National or a lawfully present individual living in the United States
• Covered California stated that my application was incomplete
• I do not have other health coverage (such as free Medi-Cal or employer sponsored insurance) that prevents me from qualifying for insurance through Covered California
• Covered California stated that I am not a California Resident
• Covered California stated that I did not pay my premiums by my due date
• Covered California stated that my MAGI income is too low chart to qualify for Covered California coverage  Get Calculation
• Other Tell us more about why you disagree with Covered California’s decision. You may attach additional sheets of paper if you need more space to write.  ^{Covered CA Appeals Request Form} *

We STRONGLY suggest you attach additional sheets of paper and explain your case, with citations, evidence & exhibits.   Be sure to read all the helpful aids we have on this page.  You are going up against well versed opponents!

Resources & Links

• Covered CA – Request to Amend Personal Information
  • coveredca.com/ombuds-office/
• California Administrative Law
  • Information on locating California regulations, guidance, administrative decisions, and executive orders and proclamations online and at the UCLA Law Library.
    • Privacy – Covered CA Appeals – Administrative Law Court WELFARE AND INSTITUTIONS CODE 10500 – 10985

How to file #Medicare appeals, deal with issues, claims, problems, etc.

• Medicare Appeals can get complex, so we won’t really try to summarize it. Please review the brochures, information and links below and on your right.  Appeals are a complex subject we are giving you mostly official guides and not our summary, advise or essays.
• Medicare Complaint Form on Medicare.Gov
  • See also Fillable pdf  10287 pdf
  • How to file a complaint – Medicare.Gov
• Medicare Advantage – Livanta
• Medicare Appeals Publication # 11525 60 pages
• File complaint against Medicare itself?
• Medicare Contact Info  *  More  *  Forms  *
• HICAP CA  * Rest of USA *  (Health Insurance Counseling and Advocacy Program)
• National Center on Law & Elder Rights – Case Consultation for Professionals
• Sample Evidence of Coverage – Medicare Advantage
  • This is NOT sales literature, but is provided as a public service for educational purposes.

#Medi-Cal Appeal & Hearing Rights

Health Care Services and Benefits

• ​​Medi-Cal Fair Hearing  Dhcs.ca.gov
• 
• You have the right to ask for an appeal if you disagree with the denial of a health care service or benefit.
  • • You can also file a hearing request online at:
    • cdss.ca.gov/hearing-requests 
•  
•  ^{MyMedi-Cal Pamphlet} *

What is the #unauthorized practice of law?

 Unlawful Practice of Law [§6125 – 6133]

California broadly defines the “practice of law” as dispensing legal advice or service, even if the advice or service does not relate to any matter pending before a court. * ^{Legal Advice vs Legal Information} * ^{Shouse Law} *    ^{(Mickel v. Murphy (1957) 147 Cal.App.2d 718, 721.)    Davis Stirling.com *} Advising HOA  boards on how the statutes pertain to them or what actions would violate the law or the governing documents. * ^{Supreme Court opinion.} *  ^{Davis Stirling.com} *1.  Advising HOA boards about rights, duties and liabilities. That includes but is not limited to:

• Interpreting the Davis-Stirling Act,
• Interpretation of contract provisions,
• Disputed maintenance and repair issues,
• Settlement issues.

2. Preparing documents that alter rights, duties and liabilities. Managers and management companies can prepare documents that are incidental to the regular course of their business. Anything beyond that must be prepared by legal counsel. That includes but is not limited to:

• Amendments to CC&Rs, Bylaws, and Articles of Incorporation,
• Contracts and contract provisions,
• Election rules,
• Rules enforcement policies,
• Settlement agreements, and ^{Davis Stirling.com} *

What is “#Advice?”

Legal advice refers to the written or oral counsel about a legal matter that would affect the rights and responsibilities of the person receiving the advice. In addition, actual legal advice requires careful analysis of the law as it applies to a person’s specific situation – as opposed to speculation based on generic facts. From a legal standpoint, the giving of legal advice is tantamount to the practice of law, In a nutshell, legal advice has the following characteristics:

• Requires legal knowledge, skill, education and judgment
• Applies specific law to a particular set of circumstances
• Affects someone’s legal rights or responsibilities
• Creates rights and responsibilities in the advice-giver

Unlike legal information – such as information posted on a street sign – legal advice proposes a specific course of action a client should take. For instance, it’s the difference between telling someone what to do (legal advice) as opposed to how to do it (legal information). Examples:

• Selecting, drafting, or completing legal documents or agreements that affect the legal rights of a person
• Negotiating legal rights or responsibilities on behalf of a person
• Speculating an outcome
• Selecting or filling out specific forms on behalf of a client  ^Findlaw.com *

Webster Definition

Links & Resources

Claim Splitting – #Res Judicata

you can’t just sue someone two or more times to get around the small claims court limit.

Laws Against
Claim Splitting – Preclusion – Res Judicata

You Tube Video’s on Res Judicata (Double Jeopardy)

• Res Judicata –Double Jeopardy
• Tutorial Res Judicata

1. Rule:
   1. If judgment is rendered in favor of a plaintiff in a particular suit, the plaintiff is precluded from raising claims (in any future litigation) which were raised in (or could have been raised) in that lawsuit.
2. Elements:
   1. Before a court will apply the doctrine of res judicata to a claim,  three elements must be satisfied:
      1. There must have been prior litigation in which identical claims were raised (or could have been raised). In general, claims are sufficiently identical if they are found to share a “common nucleus of operative fact.”
   2. scope:
   3. Res judicata bars relitigating of claims that were previously litigated as well as claims that could have been litigated in the first lawsuit.   ^{Up Counsel.com    caught.net}

If your claim is over the small claims monetary limit,you may file a case in the regular superior court, where you can either represent yourself or hire an attorney to  represent you. Instead of doing that,you may choose to reduce the amount of your claim and waive(give up) the rest of the claim in order to stay within the small claims court’s monetary limit on claims. Before reducing your claim, discuss your plans with a small claims adviser or an attorney. Once the dispute is heard and decided by the small claims court, your right to collect the amount that you waive will be lost forever.

Definition – Claim Splitting lectlaw.com Dividing a single or indivisible claim or cause of action into separate parts and bringing separate suits upon it, either in the same court , or in separate courts or jurisdictions.

Res Judicata

You cannot divide a claim into 2 or more claims (called claim splitting) just to avoid the limit…..Or, lower the amount you ask for and give up (or waive) the rest. That way you can keep your claim in Small Claims court.
.occourts.org

fees charged by the attorney for private assistance are not recoverable as court costs or damages. (dca.ca.gov)

Small Claims Procedures & Practices
§6.14 Res Judicata

• Under the doctrine of res judicata, a small claims court judgment is a bar to a second suit on the same cause of action. [Pitzen v Superior ; ^{Allstate Ins. Co. v Mel Rapton, Inc. (2000) 77 CA4th 901, 905.] * Allstate v Rapton – waiver of damages over $5k limit,}
• A small claims judgment for a plaintiff, however, is not given collateral estoppel issue-preclusion effect on other actions against the defendant. It would be unfair to have plaintiff’s choice of small claims court bind the defendant when the record does not fully reflect the issues raised and decided there. [Sanderson v Niemann]
• But a defendant may raise collateral estoppel issue preclusion if the defendant prevailed in a previous small claims action. There is no rationale for refusing to afford collateral estoppel effect to issues litigated and decided against a plaintiff. Fundamental fairness dictates that a plaintiff who chose to litigate in small claims court cannot cite the informality of that forum to gain a second chance to litigate a decided issue. Relitigating decided issues is also inconsistent with the public policy that a small claims plaintiff is bound by an adverse judgment. [Bailey v Brewer; Pitzen v Superior Court] ^{§6.14 Res Judicata} 
• If you do try to unlawfully collect a debt by claim splitting – you might get busted under Fair Debt Collection Laws!

“Dismissed Without Prejudice” – What does it mean?  Shouse Law.com