August 2012
A recent press release states, "The California Secretary of State announced today that a ballot initiative to require health insurance companies to publicly justify and get approval for rate increases before they take effect has qualified for the 2014 ballot." The release goes on to state, "the initiative would require health insurance companies to refund consumers for excessive rates charged as of November 7, 2012 even though voters will not vote on the initiative until a later ballot."
The President of Consumer Watchdog stated, "Californians can no longer afford the outrageous double-digit rate hikes health insurance companies have imposed year after year, and often multiple times a year. This initiative gives voters the chance to take control of health insurance prices at the ballot by forcing health insurance companies to publicly open their books and justify rates, under penalty of perjury. Health insurance companies are on notice that any rate that is excessive as of November 7th 2012 will be subject to refunds when voters pass this ballot measure." This effort was supported by State Senator Dianne Feinstein and California Insurance Commissioner David Jones.
Is there more to the story? Is there something else we should be considering? Is it really this obvious that this is solving a major concern or problem?
As with most sensational statements, there is far more to consider as it relates to the affordability of health insurance. As a professional actuary for more than 41 years, I am afraid there is far more to this story than has been described by the proponents of this initiative. The remainder of this article will address some of the most obvious issues.
Do Carriers Intentionally Price Gouge Their Customers?
Although there always seems to be exceptions to the norm, carriers set rates based upon their historical costs and a reasonable projection of what might happen in the future. These rates are developed by professional actuaries who are subject to Guidelines for Professional Conduct that govern their analysis and review methodologies.
Rates are not made subjectively, but rather based upon extensive analysis of what costs have been. Actuaries spend endless hours reviewing the claims experience, analyzing utilization and cost levels, developing estimates of inflationary trends, analyzing operating costs and carefully projecting what future rates will need to be in order to cover costs and produce needed margins. When prior rates are inadequate, premium rates are increased on particular plans to avoid losses.
This process is very systematic and based upon detailed actuarial analyses. This process is not arbitrary or capricious, but can be challenging for some product lines. I know of no competent carrier that intentionally tries to gouge its customers, but rather the opposite. Carriers work hard to find ways to provide the greatest value to their customers and keep rates as low as possible.
It's a safe bet that claims will not have a happy ending if the treating physician has a history of being associated with poor claim outcomes. In fact, physicians rated poorly in analytic studies based on past performance are 100% predictive of high costs and inferior outcomes in future claims where they are involved. The question is, how can those providers be identified so they can be avoided?
Applying Analytics
Whether the cause of poor performance is misunderstanding Workers' Compensation or deliberate fraud, the claim results will be dismal. Nevertheless, in order to analyze provider performance, one must know where to find the data, what to look for, and how to apply the knowledge gained from analysis to achieve improved results.
Data can offer a clear picture of actual provider performance. Evaluating physician and other provider performance is a matter of scrutinizing the data using industry research to learn what to look for. In fact, leveraging published industry research is the way to skip the laborious and expensive regression analyses and other predictive modeling methods.
Industry Research Reveals What To Look For
Exposing substandard providers is a matter of integrating and analyzing the data to understand the course of the claim and the providers who were involved. Selecting the data items to monitor can be guided in the first instance by industry research. Organizations such as the National Council on Compensation Insurance, the California Workers' Compensation Institute, and the Workers' Compensation Research Institute continually publish their research based on data they collect from members. These organizations offer research regarding medical issues causing cost escalation in the industry, and usually make results available from their individual websites.
Search
Academia and other organizations produce and publish research, as well. The best way to access other research is to use Google or other search engines to find research studies regarding specific issues and interest areas. For instance, if the concern is low back pain, simply use Google to find research and scholarly articles on the topic as it relates to Workers' Compensation.
An Insurer Should Never Deny A Defense Unless Absolutely Certain There Is No Potential For Coverage
The District Court, Northern District of California, granted a motion for summary judgment in favor of KB Home in part against the Travelers in Kaufman & Broad Monterey Bay, et v. Travelers Property Casualty, No. : 5:10-CV-2856 EJD (N.D.Cal. 07/18/2012)
Background
Travelers issued commercial general liability policies to Norcraft Companies, L.P., ("Norcraft") a cabinet installer. The Norcraft policies provide coverage for "property damage" arising out of an occurrence that takes place in the coverage territory and that occurs during the policy period.
Subcontract And Aldrich Action
On or about January 22, 2003, and February 5, 2003, KB Home and Norcraft entered into subcontracts to furnish, deliver and install cabinets at certain homes within two housing developments in Monterey, California. The subcontracts required Norcraft to name KB Home as an additional insured under its commercial general liability policies.
On October 21, 2008, a number of homeowners commenced a lawsuit in Monterey County Superior Court against KB Home, Aldrich, et al. v. KB Home, et al. ("Aldrich Action"). The homeowners alleged a number of construction defects, including "cabinet and wood trim" defects, that resulted in damage to the homes and their component parts.
KB Home filed a cross-complaint against various parties, including Norcraft, alleging among other things that Norcraft is contractually required to defend and indemnify KB Home with regard to the Aldrich action.
Travelers' Acceptance, Withdrawal, And This Action
On April 1, 2009, Glaspy & Glaspy, counsel for KB Home, tendered the defense and indemnity of KB Home as additional insureds under the Norcraft policies in the Aldrich action. This initial tender included copies of the original Complaint, First Amended Complaint, KB Home's Cross-Complaint, a Stipulation and Order of Reference to the Special Master, the Subcontract and additional insured documentation.
On April 6, 2009, Patricia E. Dlugokenski ("Dlugokenski"), a senior technical specialist for Travelers, acknowledged receipt of the tenders and requested additional information, including: a statement of claims or documentation related to the alleged defects and deficiencies, expert investigation reports into defects or damages, current pleadings and any Case Management Order or Pre-Trial Order documents, and the location of any document depository.
On April 6, 2009, in response, KB Home provided an updated Homeowner matrix, the amended complaint, and the dismissal of one of the plaintiffs' homes. KB also informed Travelers that the Pre-Trial Order had not yet been filed and there was no defect list but that KB Home would forward the defect list as soon as it is received. On July 6, 2009, Dlugokenski noted in the internal Claims Notes that "it is likely some, although minor damages resulted from [cabinet] installation. Damages to the walls or pulling away from the walls could be attributed to installation." (Emphasis added) Also on July 6, 2009, Dlugokenski issued a letter accepting KB Home's tender as additional insureds under the Norcraft policies.
On July 26, 2012, a federal judge in Las Vegas ordered Prospect Airport Services, Inc., a provider of wheelchair assistance services to airline passengers, to implement extensive measures to prevent future sexual harassment.
After agreeing to a monetary settlement of $75,000 in a lawsuit brought by the the Equal Employment Opportunity Commission, Prospect refused to agree to any prospective relief to prevent future harassment. The Equal Employment Opportunity Commission petitioned the court for an injunction and order directing compliance.
The judge issued an order prohibiting Prospect from further violating Title VII as it relates to sexual harassment for a period of five years. Prospect must develop a policy and procedures for handling reports of sexual harassment and an effective investigation process for all harassment complaints. It must also "appropriately discipline management and human resources staff for failure to comply with such procedures and provide annual sexual harassment training to all supervisory employees."
The Equal Employment Opportunity Commission will monitor compliance and can haul Prospect into court again for any failure to comply with these orders or for damages based on new harassment incidents.
The Equal Employment Opportunity Commission had charged the company with failing to address complaints of unrelenting sexual advances toward a male passenger services assistant by a female co-worker. The employee, whose wife had passed away, received sexually suggestive notes and unwelcome advances. He rebuffed the advances and brought the notes to the attention of a general manager who made light of the situation and failed to stop the harassment. There was no effective company policy at the time to address the issue.
Over the course of a year, the harassment escalated to a near-daily basis, including offensive remarks by co-workers about his sexuality due to his rigorous rejection of the sexual advances. Despite his repeated complaints to management, the hostile work environment ended only when he resigned.
Employers And Plan Fiduciaries Reminded To Confirm Credentials And Bonding For Internal Staff, Plan Fidiciaries And Vendors Dealing With Benefits
Businesses sponsoring employee benefit plans — along with officers, directors, employees and others acting as fiduciaries with respect to these employee benefit plans — should take steps to confirm that all of the appropriate fiduciary bonds required by the Employee Retirement Income Security Act of 1974, as amended (ERISA) are in place. They should also confirm that all employee benefit plans sponsored are appropriately covered, and that all individuals serving in key positions requiring bonding are covered and appropriately qualified to serve in that capacity under ERISA and the terms of the bond.
Adequate attention to these concerns not only is a required component of ERISA's fiduciary compliance, it also may provide invaluable protection if a dishonesty or other fiduciary breach results in a loss or other exposure.
ERISA generally requires that every employee benefit plan fiduciary, as well as every other person who handles funds or other property of a plan (a "plan official"), be bonded if they have some discretionary control over a plan or the assets of a related trust. While some narrow exceptions are available to this bonding requirement, these exceptions are very narrow and apply only if certain narrow criteria are met.
Plan sponsors and other plan fiduciaries should take steps to ensure that all of the bonding requirements applicable to their employee benefit plans are met at least annually. Monitoring these compliance obligations is important not only for the 401(k) and other retirement plans typically associated with these requirements, but also for self-insured medical and other ERISA-covered employee benefit plans.
This process of credentialing persons involved with the plan and auditing bonding generally should begin with adopting a written policy requiring bonding and verification of credentials and that appropriate bonds are in place for all internal personnel and outside service providers.
Cost Retention and Safety Enhancement: Protecting Your Assets
While construction activities are fluctuating due to the current economic situation, general, heavy/highway and specialty contractors continue to face increasing consumer and regulatory demands and requirements to provide a safe, healthy and secure work environment for their employees.
However, the consequences of theft and lack of security in the workplace are not always understood. Several states have contractor-based trade associations who partner with law enforcement, e.g. the Construction Industry Crime Prevention Program (CICP), which monitors, participates and assists contractors in protecting your assets.
To test your knowledge, Take the Crime Quiz
True or False:
1. Substance abuse is an important factor contributing to crime.
Unfortunately, True. The Construction Industry Crime Prevention Program has been notified that some construction firms have relaxed their hiring standards, including substance abuse polices, because of the severe labor shortage. Employee theft accounts for around 85% of a firm's theft problem. One employee with a substance abuse problem can be a firm's entire theft problem in addition to creating a safety problem on the jobsite.
2. Attitude has nothing to do with theft on a jobsite.
False. Rationalization and opportunity are two of the leading factors in employee theft. The common rationalization from some employees is "The contractor leaves all these tools, generators and equipment unprotected, because they are so rich. Obviously they don't care. Besides, I need a drill at home." Congratulations, you have just had a theft.
Most construction firms provide the opportunity for theft if there is poor or no inventory control at a jobsite, lack of inventory accountability, no one is watching payroll checks, or the firm is willingly handing out replacement tools and materials.
Yesterday the California Supreme Court issued its long-awaited decision in State of California v. Continental Insurance, No. S170560. In its latest ruling, which will affect all long-tail insurance cases, including Environmental, Asbestos and latent injury, and Construction Defect cases, the Court rejected the "pro rata" time on the risk allocation scheme advocated by the insurers and held:
- For indemnity relating to "long tail" claims1, the "all sums" language in the Comprehensive General Liability (CGL) policies obligates a carrier to indemnify up to the policy limits, so long as some portion of the "property damage" that is the subject of the suit occurred during the policy period; and
- The insured is entitled to "stack" the limits of successive policies up to the policy limits for indemnity relative to that loss.
The case arose out of the State of California's claim for indemnity under its excess Comprehensive General Liability policies in connection with a federal court-ordered cleanup of the State's Stringfellow Acid Pits waste site. The State designed the Stringfellow site, and operated it as an industrial waste disposal facility from 1956 to 1972, when groundwater contamination was discovered. In 1998, a federal court found the State liable for all past and future cleanup costs for the site. Each of the six insurers that were parties to the appeal issued excess Comprehensive General Liability policies to the State between 1964 and 1976.
The Stringfellow site, and the resulting insurance litigation, has given rise to several insurance rulings already, including Montrose Chemical Corp. v. Admiral Ins. Co. (1995) 10 Cal.4th 645 — adopting the continuous injury trigger for defense, and State of California v. Allstate Ins. Co. (2009) 45 Cal.4th 1008 — holding that the relevant event to determine if there is an "occurrence" is the discharge into the environment from a contained area, and that where there is an indivisible injury, the insured is not obligated to prove the amount of any property damage resulting from any discrete cause.
There are several critical aspects of the Court's decision.
First, there was no dispute that the environmental damage began shortly after the operation of Stringfellow began, and that it continued throughout the defendant insurers' policy periods and beyond. According to the opinion, the site was uninsured prior to 1963, and after 1978. The issue, therefore, was whether the State of California could be allocated partial responsibility for the cleanup costs for the amount of property damage occurring in years where it was self insured. This fact pattern — where there is insurance for some but not all of the affected years — is common in "long tail" or "progressive loss" type cases. A carrier with only one year of coverage could potentially be responsible for all damages regardless of the length of time over which the property damage occurred.
Musculoskeletal Disorders (MSDs) represent 28% of all recordable OSHA injuries and account for 33% of the total cost of work-related injuries. Each recordable OSHA musculoskeletcal disorder involving lost time results in an average of 20 or more lost work days, compared to 9 lost work days for all other recordable injury types. Since the enactment of OSHA in 1970, the regulations have evolved to increasingly focus on the reduction of job hazards potentially leading to fatalities, amputations, and other serious injuries. Accordingly, a significant decline in the number of those types of injuries is evidenced in OSHA's records. However, muskuloskeletal disorders and other "soft tissue" injuries continue to plague workers and their employers with no indication of decline.
In fact, all indications point to an increase in muskuloskeletal disorders given that the percentage of workers ages 55-64 will increase by 36% during the next 5-year period while the percentage of workers under the age of 25 will decline. Obviously, older workers are more susceptible than younger workers to work-related muskuloskeletal disorders because of decreasing functional capacity due to degenerative conditions, pre-existing conditions and old injuries. Also troubling about this muskuloskeletal disorder injury forecast is the fact that older workers require longer recovery periods, inevitably driving up direct medical and disability costs. Indirect costs include overtime, training, and lost productivity related to injured workers' inability to perform their normal work. According to OSHA, for every $1 of medical-only claims, employers sustain $4.50 in indirect, uninsured costs.
Safety is an investment in future profitability for every employer and the well-being of every worker. However, an employer must exercise caution in its safety programs so as to avoid OSHA's anti-discrimination policies. Recently, Richard Fairfax, OSHA's Deputy Assistant Secretary, issued a memo addressing employers' safety incentive programs and suggesting that some such programs are merely a pretense to save workers' compensation costs and actually resulting in discriminatory disincentive policies and practices. Fairfax's memo emphasizes that a worker's reporting of a claim is a protected act, and identifies four approaches that potentially expose the employer to discriminatory practices:
- Taking disciplinary action against injured workers;
- Penalizing injured workers for failure to timely report an injury;
- Penalizing injured workers for violation of safety rules; and,
- Implementing certain performance incentive programs.
Just when you thought that everything was settling down, the "Slither-Ins" from the Dark Side have once again reared their ugly heads. The latest and ongoing attempt to seize control over your claims goes like this:
Employers currently have a minimum of 30 days within which to control the medical treatment of an injured employee. This remains true unless the employee has correctly "Pre-designated" his or her Primary Treating Physician before the injury. If you are smart enough to have a Health Care Organization (HCO) in place, you have a minimum of 90 and possibly 180 days of absolute medical control over the claim. Or, if you have put a Medical Provider Network (MPN) in place, you have cradle-to-grave control over the medical treatment of your injured employee if it is handled correctly by both you and your insurance carrier.
Your ability to retain control is a given unless you do not follow the rules regarding the treatment of an injured employee. It is in the initial stages of the claim that you are most vulnerable and subject to having your control taken away by an attorney/doctor team from the dark side if you do not strictly follow the letter of the law. However, do not despair as we have once again been forewarned of their latest tactic and are ready to meet them head-on.
You Have To Open The Mail Every Day
The current law (L/C 5401) says "Within one working day of receiving notice or knowledge of injury under Section 5400 or 5402, in which an injury results in lost time beyond the employee's work shift at the time of injury or which results in medical treatment beyond first aid, the employer shall provide, personally or by first class mail, a claim form and notice of potential eligibility for benefits."
This is the first place that the applicant's attorney is going to try to get you. If you have not provided the Workers' Compensation Claim Form (DWC-1) to the injured employee, they will claim that you failed to follow the law and will attempt to seize control regardless of the medical control program you have in place. It is therefore important that this requirement be strictly adhered to by the person within your organization who you have designated as being responsible for watching your workers' comp claims.
Within the warehousing industry, a business owner might find themselves offering services to their clients that are not usually covered under the warehouse policy or the general liability policy. Coverage for these services can only be found under a professional liability policy.
A general liability policy usually contains some type of professional liability exclusion. Specifically, the insurance carrier will pay those sums that the insured becomes legally obligated to pay as damages because of "bodily injury or property damage". Clearly, if there is no bodily injury or property damage but rather an economic loss, this type of loss would not be covered as it does not fall within the coverage definition.
Logistics Management Errors & Omissions Liability Insurance is designed to cover those exposures that fall outside the general liability policy. This policy will pay on behalf of the insured those amounts in excess of the deductible that the insured becomes legally obligated to pay as damages from claims as a result of a wrongful act.
Wrongful act means any actual or alleged act, error or omission in the rendering of or failure to render "Contract Logistics and Supply Chain Management Services." Services also means those services you are qualified to perform as a Consolidator, Customs Broker, Freight Forwarder or the policy can be endorsed with special wording regarding other services related to supply chain management. Service is further defined in the policy as:
- the development and preparation of studies, process analysis, evaluation studies, transportation or routing analysis and re-engineering studies
- the design, development, modification, maintenance, licensing, sale, operation or use of logistics or supply chain management algorithims
- the design, development, modification, maintenance, coding, integration, licensing, sale or operation of software used in logistics or supply chain management
- logistics management
- truckload management
- shipment management
- inventory management
- transportation management
- records retention and management
- vehicle location and tracking
- supply chain coordination and management
- facilities and warehouse management
- data processing and electronic data interchange
- computer network access management, administration and support
- internet access, connectivity and support
- intranet or extranet access, connectivity, management and support
- training and supervision, and selection and oversight of vendors, service providers and subcontractors, including carriers, consolidators, brokers, agents and freight forwarders.
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Whether it’s Healthcare, Worker’s Compensation, Property & Casualty, Auto, Sophisticated Life Insurance designs, Directors & Officer’s, Safety, Risk Control or other Claims Management, Insurance Thought Leadership promises to deliver the most relevant mind share the industry has to offer.
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Dave Dias
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