Maryland Injury and Disability Law : Washington DC Metro Injury & Disability Lawyer & Attorney : Greenberg & Bederman : Accidents, Falls, Medical Malpractice : Maryland, DC, Virginia

Washington Post, 1/5/11-A man has died in an area hospital several days after he was in a Christmas Eve car crash that also killed his father, Loudoun officials said.

Timothy D. Doane, 49, of Harpers Ferry, W. Va., died Tuesday. His father, David Doane, 76, of Tennessee also was killed in the three-car crash. A third man is in critical condition at an area hospital, authorities said.

The accident happened at 3:30 p.m. at Route 9 just west of Creamer Lane.

George Radston, 58, of Ashburn was driving eastbound in a Pontiac when he lost control on a curve, crossed over the roadway centerline and struck a 2010 Toyota Prius with the Doanes inside.

After striking the Toyota, the Pontiac continued to roll, ejecting Radston. He remains in critical condition. The Pontiac also struck a 2003 Volkswagen Jetta, and the 22-year-old driver and her passenger sustained minor injuries.

This is about as bad a scenario as you can get. It appears that the man driving the Pontiac simply lost control. It doesn’t say whether or not he was speeding or driving recklessly, or if he was driving while intoxicated. Sometimes, things just happen. Roads get icy or slippery or tires can lose traction. Not every accident is a cut and dried case of negligence or irresponsibility.

Those situations are the difficult ones to handle. If there isn’t a mistake or a miscue, or if nobody was texting while driving or playing with the radio, what do you do? How is this handled?

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Are you tired of the runarounds, denials, and rate hikes of health insurance carriers such as Cigna, Aetna, Blue Cross/Blue Shield and United Health Group? Have you tried to take your business somewhere else? Have you ever tried to find a small, mom and pop style health insurance company in Maryland, D.C. or Virginia?

Good luck with that. There aren’t any.

Every health insurance option that you have in the D.C. metropolitan area is either a direct subsidiary of an enormous health insurance conglomerate or is an enormous health insurance conglomerate. “Taking your business elsewhere” simply means going to another company that will charge you exorbitant amounts of money for the same shabby treatment. 

The reason this is the case is because there is nothing keeping health care giants from buying out or muscling out any other health insurance company that tries to set up shop. Ordinarily, this would be called a “monopoly,” which is supposed to be against the law. It’s the reason that there is a Ben and Jerry’s and Baskin Robbins. It’s the reason that there is Coke and Pepsi, as well as RC or the generic version that you can buy at any supermarket. It is illegal for any one entity to corner the market of any product or service. The only two entities that are exempt from setting up monopolies are Major League Baseball and health insurance.

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Insurance Rules in the Metropolitan D.C. Area

Life in Washington, D.C. is different than other parts of the country, and that’s not just because of our proximity to Government. What’s different about our area is that there are essentially three different states within a ten minute drive of each other. There is Maryland, Virginia, and the District of Columbia, each separated by a few miles and each with separate governments, rules, regulations and requirements. We know that it doesn’t seem that way sometimes, but things are actually done differently in Maryland than they are in Virginia and vice-versa. And the District is essentially an enclave under the auspices of the U.S. Government. So if you decide to move across the Potomac at the 14^th Street Bridge the rules governing your car insurance requirements change, just as they do when you cross the Woodrow Wilson Bridge or the Cabin John Bridge. This doesn’t happen to people who live in, say, Central Illinois or Wyoming.

One of the main differences in the rules is the insurance minimums. These are the amounts that all drivers are required to have by law in Maryland and the District, but not necessarily Virginia (more on this later.)

In Maryland, drivers are required to have $20,000 worth of coverage to handle the bodily injury or death of another driver. They are also required to have $40,000 worth of coverage for the bodily injury or death of multiple people, be it the other driver and/or passengers. There is also a property damage requirement of $15,000, which is supposed to cover any damages to other cars or buildings or anything else that happens to be damaged in the event of an accident.

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We understand completely the idea of incentives in the workplace. If an employee does his job particularly well, we think a reward system of some kind makes perfect sense. Such a system is good for both the employee and the employer, as it encourages the employee to work harder while the employer reaps the benefits of those labors.

Performance based initiatives are great if you happen to be selling cars, or making donuts or tires. But we have a real problem with the idea of rewarding employees for denying crucial and needed services. And this is exactly what is happening with health care in California, and possibly all over the country.

A recent article in the Los Angeles Times details the inner workings of Blue Cross of California, in which employees are rewarded not for providing medical care, but rather for denying it.

“The documents show, for instance, that one Blue Cross employee earned a perfect score of "5" for "exceptional performance" on an evaluation that noted the employee's role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care.”

Bear in mind that this employee was not rewarded for selling more policies, or cutting delays of payment, or even having a sunny disposition with customers. This employee was rewarded for cutting policyholders who might have actually cost Blue Cross money. This employee was rewarded for denying insurance claims. This employee was rewarded for leaving sick people in serious financial trouble.

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The Heathcare System and Medical Bills

Perhaps one of the saddest things about our healthcare system is that there is an occupation dedicated towards correcting what hospitals and insurance companies get wrong. And it isn’t the lawyers, believe it or not.

There are people out there called “medical billing advocates,” and their job is twofold: First, they make sure that all medical charges from the hospital are legitimate, and secondly, they help convince insurance companies to pay for medical claims that were denied for no good reason.

Most of them don’t charge by the hour. Just like injury attorneys, they charge as a fee a percentage of the money that they save you. While we are glad that such a position exists, we think it’s quite sad that they have to be in business at all. We are equally sad that business is apparently booming for them.

According to a group called the Medical Billing Advocates of America, there are errors on fully 80% of medical bills. And by “errors” they don’t mean mistakes in spelling in punctuation. We mean charges that are made that shouldn’t be there.

There are duplicate charges, price gouges, and “creative rebranding” of standard things in order to make them seem more expensive than they really are. For instance, one bill that was scrutinized listed a box of tissues as a “mucus suppression system.” A box of tissues at the average grocery store will run you $2.00. But a “mucus suppression system at the local hospital will run you $30.00. A second bill that was scrutinized charged some poor child $100.00 for the use of a teddy bear, which was billed as a “cough support system.” A single Tylenol, which is listed as “pain relief therapy”can cost you about $25.00.

Overnight stays also provide a billing bonanza for hospitals. Normally the room is supposed to have a flat rate, just like in the Holiday Inn. But quite often you will see surcharges for sheets, bedding, heating and/or cooling costs, extra blankets, and the electricity that it costs to run the television/adjustable bed/heart monitor.

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In the current health care debate, we hear many of the naysayers use the argument that they don’t want “some faceless bureaucrat in Washington making decisions about our healthcare.” We find that argument strange, mainly because as things stand right now, decisions about your healthcare are made by a faceless insurance adjuster. The decisions aren’t based whether or not the treatment is what’s best for the patient, but rather on whether or not the insurance company is willing to pay for them. We have noticed that many of the scare tactics used by opponents of health care are simply recitations of the status quo. They aren’t creating the imagery of some Orwellian nightmare as much as they are simply shining a spotlight on how things currently are.

As an example, consider the case of James D, who suffered a broken leg.  At the time of his injury, he was an editor at the Washington bureau of a well regarded science magazine.  His employee health insurance was covered by United Health Care, which is one of the largest private medical insurers in the United States.

What was thought to be a straightforward injury claim turned into an 18 month odyssey in which James was facing $30,000 worth of denied medical bills.  Anyone who believes that health care coverage in this country does not need reforming should probably hear his story.

GB: Tell us about the circumstances of your injury.

JD: I slipped and fell and broke my leg in three places. That was all there was to it. This was during the winter, and it was snowing outside, and I thought I had salted the walkway to my house the night before as well as I could, but it seems that I missed a spot. That was the spot that I stepped on the next morning, of course. I stepped on some ice, and I fell, and there went my leg.

GB: That could have happened to anybody.

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This is a true story that Greenberg & Bederman is sharing that happened to a colleague of ours to illustrate yet another reason our country is in a healthcare crisis.

Back in 2003, I got sick.

I know that isn’t the most earth-shattering of statements. Everybody gets sick, after all. But I got VERY sick.

At the time, I had just gotten out of college and was struggling to find a job. In order to pay the bills I began substitute teaching, which meant that every day I was sent into a different classroom full children, with the age ranging anywhere from 5 to 17. On occasion I would end up in a high school, but for the most part my duties would involve looking after grade school students.

Young children, as many of you who are parents may know, are quite susceptible to illness and infections. And considering that I was a bachelor in his twenties, I can tell you with great certainty that my immune system wasn’t exactly operating at its peak performance. So within three weeks of starting my substitute teaching duties, I got a sore throat.

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In the twenty five years since we began our practice, one constant that we hear quite often from many of our injury victim clients are worries about “Pre-existing conditions.”

The style and syntax of the worries vary from person to person, but if we were to average them out into one sentence it would be this:

“The insurance company says that they won’t pay for the needed treatment because they say that the reason the injury was so bad was because of a pre-existing condition.”

If that seems a little hard to follow, here is a more concrete example.

Mr. X is driving down 395 at fifty miles an hour. A car in the lane to his right suddenly swerves into his lane without signaling. Mr. X’s car is sideswiped and is sent careening into the highway divider. Mr. X suffers a dislocated shoulder when his body slams up against the seatbelt.

Mr. X already has a particularly weak shoulder due to the fact that he used to be on the wrestling team in high school and suffered from a torn rotator cuff. Because of this previous damage, it will take surgery and physical therapy in order to get Mr. X’s shoulder back to normal.

The insurance company of the driver that hit Mr. X tells him that they will only pay for a pre-determined amount, which is usually an “average” of what they think a similar injury would cost. As far as they are concerned, the costs of the extra surgery and the physical therapy are not their problem, because these conditions were “pre-existing,” or, Mr. X had these problems before the accident occurred.

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On June 15^th, President Obama gave a speech to the American Medical Association in Chicago. Considering that a big part of the President’s agenda involves health care, it can be assumed that he attached a great deal of importance to this speech. Any kind of health care reform would be very difficult to pull off without the support of the biggest and most influential medical advocacy group in the country.

Right off the bat, Mr. Obama offered a real example as to the realities of our health care system when he described the working day of a doctor in New Hampshire:

“Our costly health care system is unsustainable for doctors like Michael Kahn in New Hampshire, who, as he puts it, spends 20 percent of each day supervising a staff explaining insurance problems to patients, completing authorization forms, and writing appeal letters; a routine that he calls disruptive and distracting, giving him less time to do what he became a doctor to do and actually care for his patients.”

He also gave an example as to how things were going among those of us who have to pay for the premiums:

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There doesn’t seem to be much you can do to avoid the high cost of health care these days.

In 2008, total spending on health care was $2.8 TRILLION. In case you aren’t sure how much that is, it’s enough to pay for all the goods and services produced in Australia in one year. It’s enough to fund the military of every country in NATO combined. It’s more than the value of every stock on the Toronto Stock Exchange.

It is, in short, a whole lot of money.

For those of us who have health insurance, that $2.8 trillion doesn’t just factor in the trips you make to the doctor or the deductibles that you have to pay. It also factors in your monthly insurance premiums, and any prescriptions that you have to have filled. Those of us without health insurance are also contributing a great deal to the overall total.

The vast majority of us in this country aren’t too thrilled about this, but we can tell you with great certainty that HMO’s, pharmaceutical companies and insurance companies are as pleased as they could possibly be with those numbers.

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Is getting ripped off “Usual” and “Customary?”

For the health care consumers all over the country, that has apparently been the case.

Back in January, New York Attorney General Anthony Cuomo pulled the plug on Ingenix, owner and operator of the biggest health care billing software in America.

The reason Ingenix was targeted by Mr. Cuomo was because of its billing practices when policyholders used out of network services. The “out of network” option is offered as a service on many health care policies, for which policy holders usually pay extra. If through choice or circumstance you found yourself using the services of a health care provider who isn’t affiliated with your health plan, the “out of network” option is supposed to cover somewhere in the neighborhood of 80% of the cost while you pay the rest.

But it didn’t work like that in real life. If the insurance companies simply said “Ok, you have a bill for $1000, we’ll pay $800 and you’ll pay $200,” Ingenix wouldn’t have had a reason to exist at all. Instead, Ingenix used its software to apply a sort of alchemy to its billing practices, with the end result being that policyholders who were using out of network services were being forced to pay way more than they should have. The rub in the software came in what was called the “Usual and Customary” rate, with “Usual and Customary” meaning the “average” costs for a given service.

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The Colossus Program

Insurance claims adjusters used to be people who were well trained and thoroughly experienced. They had to know about car accidents, repair costs, medical costs and economics. They had to go through each individual accident claim and factor in how much it would cost to repair the car, how much the medical bills could reasonably be expected to cost, how much money the accident victim would lose because of time missed from work, and basically get a handle on any conceivable monetary issues that might come up during the course of the claim.

That sort of expertise isn’t required anymore. These days, insurance adjusters are essentially no more than cubicle dwelling button pushers who don’t need to know much of anything about the costs of car accidents, or medical bills, or economic loss. A computer program called Colossus handles all of that for them.

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Bad Faith and Insurance

On the surface, an insurance policy seems like a straightforward proposition. You pay an insurer a certain amount of money every month in case something bad happens, and if something bad does occur, the insurer is supposed to provide the funds necessary to see you through it.

But as many injury victims have found out, it’s hardly ever that simple.

Insurance companies seem to live in a parallel universe where a contract is more of a suggestion rather than a binding legal agreement. Many insurers routinely offer settlements that are worth much less than what would be necessary to cover the damages. And if these initial offers are refused, they have the time and money to simply wait out the injury victim. They don’t return calls and ignore e-mails, secure in the knowledge that at some point the injury victim will start to need any bit of money that they can get.

This might seem like something that a fly-by-night insurance company would do, but in fact these are standard procedures used by some of the biggest insurers in the country.

For instance, Allstate has recently been exposed as using the “wait it out” method of dealing with those who file claims:

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