Articles Posted in Insurance Coverage

According to the Boston Globe, the Massachusetts Insurance Carrier, Commerce Insurance has agreed to settle a lawsuit against them by the State attorney general’s office as a result of unfair billing practices. Commerce Insurance admitted to overbilling their policy holders because they overvalued motorcycles and did not account for depreciating values of older motorcycles.  As part of the agreement, Commerce will be paying over $15 million in refunds to their policy holders.

Commerce Insurance writes the largest share of auto and motorcycle insurance in the state of Massachusetts. Pursuant to the settlement, Commerce will be sending back to customers checks ranging between $50.00 all the way up to $12,000.00. The average return will be $360.00 per policy holder.

The investigation began when a policy holders complaints went unanswered by the insurance company.  Eventually the State Attorney General’s office became involved and performed a 4 year investigation into the billing practice of Commerce Insurance. The overcharging of premiums to individuals holding auto and motorcycle policies is troubling.  If the Massachusetts Attorney General’s office did not get involved, this insurance company would have reaped the benefit of overcharging at the expense of the public.

A District Court in Massachusetts allowed a Hospital located in Concord to proceed with a trial to recover personal injury protection benefits resulting from an auto accident.  See Emerson Hospital v. Amica Mutual Insurance Company.  Amica Insurance Company argued their failure to pay for medical services to the Hospital after an auto accident was proper because the injured party did not return a PIP application for benefits.

The court noted “the failure of the injured party to submit a PIP application does not, as a matter of law, excuse Amica Insurance Company from its PIP obligation”.  MGL c. 90, S-34M, requires that a claim for PIP benefits shall be presented to the company providing such benefits within at least two years from the date of the accident, and shall include a written description of the nature and extent of injuries sustained, treatment received and contemplated and such other information as may assist in determining the amount due and payable.   In this case, the Insurance Company took the position they are not responsible to pay for the medical services because the PIP application was not completed within 2 years, and as a matter of law, they do not need to show any prejudice.  The court determined Amica’s position is wrong because in this case, the hospital submitted the proper itemized bills listing the charges as related to emergency treatment due to the auto accident.  Furthermore, Amica did not request the hospital to submit additional evidence.  Lastly, the court determined Amica Insurance Company did not appear to send the PIP application to the correct address and did not give the injured party the opportunity to cooperate with then.

The court determined it was an error for the insurance company to believe an injured party is the only one to properly initiate a medical claim for personal injury protection benefits.  If you or a loved one is having difficulty getting an insurance company to cover medical benefits as a result of a motor vehicle accident, The Law Offices of Michael O. Smith strongly encourages you to seek the advice of an experienced attorney to protect your rights.

A US District Court Judge recently ruled the widow of a man who suffered a heart attack after a motor vehicle accident in Massachusetts is not entitled to accidental death benefits under her husband’s life insurance policy.  See Phan v Metropolitan Life Insurance Company.   The insurance policy contained an exclusion stating the policy holder is not entitled to accidental death benefits if the accident was “in any way” related to a physical illness.  The Judge ruled that one of the causes of the plaintiff’s death was cardiovascular disease and therefore the insurance company is not obliged to pay the accidental death benefit.  Furthermore, the Judge found the car accident alone was not a fatal accident and therefore, the widow is not covered the policy.

The plaintiff’s husband was covered under a life insurance policy that also contained a rider providing an accidental death benefit in addition to a general death benefit.  On August, 10th, 2011, the plaintiff’s husband was found by Massachusetts State Police on the side of interstate 95 near the edge of woods, slumped over in his car.  The car was heading south and then apparently crossed the median strip and onto the northbound lanes before it came to rest.  There were no other vehicles involved in the accident.  The Plaintiff’s husband was found unconscious by the State Police.  He was transported to Beverly Hospital where he was pronounced dead.  The autopsy report listed the “manner or death” an accident and listed “causes of death” as blunt chest trauma and cardiovascular disease.  The Plaintiff hired an expert who opined the cause of death was “blunt trauma causing a sudden and accidental cardiac event in reaction to his vehicle leaving the road”.  Unfortunately for the plaintiff their expert could rule out the possibility the cardiac event actually caused her husband to lose control of the vehicle.

The defendant insurance company, Metropolitan Insurance, hired their own expert who concluded the heart disease, not the accident, caused the plaintiff’s death.  The Judge interpreted the policy rider that provided the accidental death benefits as excluding coverage of the loss of life resulted in any way or contributed in any way by a physical illness.  The Judge concluded where the autopsy report also mentioned cardiovascular disease as a cause of death, then the plaintiff is not entitled to the accidental death benefit and can only collect on the general life insurance policy.  The plaintiff could not eliminate the cardiovascular disease as a cause of death and therefore, the exclusion applies.

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