We recently ran into a funny little twist with a UM/ UIM claim. The carrier was trying to apply a $200 property damage deductible. But the UM driver was known and identified. And under Virginia law, carriers cannot apply a deductible when the identity of the other driver is known. (They can only apply a deductible in the case of a John Doe driver.) We know this is not a huge amount of money in the grand scheme of things, especially if a claim is big enough for any of us to be involved. But it matters to many individual insureds. And it got us thinking, how often is this happening? How many smaller UM claims that never get to litigation face an erroneous deductible? If repeated that $200 could quickly add up to real money for the insurance companies. Money that they have no right to.
Which brings us to our next tidbit, the SCC’s Bureau of Insurance. While they don’t get involved in individual auto, general liability, or property claim disputes; they are very interested in systemic issues within the insurance industry. So when you encounter something flagrantly incorrect being attempted by a carrier, even if it could be an honest misunderstanding of Virginia law and regulations by an adjuster like in our case, you or your client should file a complaint with the Bureau of Insurance. They can’t do the job of policing insurers if they don’t know about problematic claim handling.
Is there any entity that does assist in any individual claim disputes? For healthcare, Yes! The Office of the Managed Care Ombudsman (scc.virginia.gov/boi/omb/) does just that—if you or a client has a denial of healthcare benefits under a managed care health insurance plan. And most healthcare plans other than military, Medicare, Medicaid, employer self-insured, etc. are managed care. They provide, at no charge, help with internal appeals. They also oversee independent external review of denials on medical grounds, with the results binding the insurance carrier. The Ombudsman is an extraordinary and free resource for combatting a big chunk of denied healthcare claims. (scc.virginia.gov/boi/omb/ext_review.aspx) Also, they’re really nice—and if they can’t help you they’ll say so and might even point you in the right direction.