Self Funded Health Insurance
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INSURANCE COVERAGE AND ADMINISTRATIVE PROCEDURES
Sam K. Abdulaziz, Esq.
A recent court decision created a substantial loophole for insurance companies,
which can hurt contractors. Although the court decision suggests that it does
nothing more than interpret an insurance policy, it doesn't make a great deal
of sense from a logical standpoint.
The case involved deciding when an insurance company has the duty to defend
and when an insurance company has the duty to indemnify its insured, in this
case, a contractor. The duty to defend requires that the insurance company pay
for the defense of a claim. The duty to indemnify requires the insurance company
pay for the covered damages found to be caused by its insured.
Most professions in the state of California are subject to a great deal of regulation.
Regulations are passed by an administrative body such as the Contractors' State
License Board. Although regulations don't carry the same weight as legislation,
they're very much part of the law governing the regulated profession. With respect
to contractors, the Contractors' State License Board has a number of regulations
concerning the classification system, discipline, etc.
Hearings pertaining to violations of those regulations are handled through the
Office of Administrative Hearings. This is an administrative court that makes
a proposed decision that the Registrar will adopt or not adopt. Quite often,
the matter being complained of is poor workmanship or deviations from accepted
trade practices.
We have always argued that if the violation of the License Law also triggers
an insurable event, then the insurance company should both defend and indemnify
the contractor, because that is the harm that was covered by the insurance policy.
This is what the contractor purchased insurance to cover. The most recent case
now holds that the insurance company has neither a duty to defend nor the duty
to indemnify the contractor in a situation pending in an administrative tribunal.
There is an axiom in the field of law that the duty to defend is greater than
the duty to indemnify. Simply stated, if any part of a claim is covered, then
the insurance company has a duty to defend the entire claim (lawsuit) even though
the result may be that a portion of the lawsuit was not covered. Based on this
theory, we have quite often asked an insurer to help in the defense of a disciplinary
matter stating that the discipline would be imposed as a result of an insurable
offense.
We have also argued that restitution ordered by the tribunal for "property damage"
is covered. However, this recent case held otherwise, based on the language
in the insuring policy. Typically, those policies discuss "a suit seeking damages"
and "all sums that the insured becomes legally obligated to pay as damages."
The court interpreted that language to mean only as a result of a civil action
would an insurance company be required to either defend or indemnify.
In other words, there would have to be a lawsuit filed in court only.
As said previously, this doesn't make a great deal of sense, but probably is
an accurate analysis in interpreting the language.
Law Offices of Abdulaziz & Grossbart
P.O Box 15458
North Hollywood, CA 91615-5458
(818)760-2000
(323) 877-5776
(818)760-3908 FAX
Web Site www.abdulaziz-grossbart.com
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International Travel and Health Insurance
David M. Schmader
Embarking on Your Dream Vacation
Are your Plans Complete?
Your bags are packed, passport and papers in order and you couldn’t be in a
higher state of excitement preparing for travel to that wonderful, exotic location.
This is the vacation you have planned it seems forever. As you sit on the plane,
you and your partner discuss for the hundredth time the scuba diving you will
do, the awesome rock climbing and hikes into the rain forest. Everything is
perfect!
Life seldom gets better than this.
Despite all the excitement of travel, Americans do have some concerns.
According to a survey by the Chubb Group, more than 70% of Americans surveyed
said their greatest concern when traveling is suffering a medical emergency...more
than double the fear of being mugged (30.7%), three times the fear of being
injured in a terrorist attack (23.4%).
What happens if a medical emergency arises when traveling overseas?
Many people assume that while they are out of the U.S. or Canada they will be
covered by their standard medical plan. However, most traditional health insurance
plans are not designed for international travel.
According to the U.S. Department of Commerce, approximately 27 million travelers
board U.S. airlines for overseas destinations and almost 26 million foreign
travelers come to the U.S. each year. However, many are not prepared for a medical
emergency abroad.
Most traditional health insurance plans would not cover an unexpected illness
or injury during international travel. But travelers with international medical
insurance would have protection for scenarios ranging from a local ambulance
trip to an emergency evacuation for care at the nearest qualified medical facility.
Some even offer repatriation flights out of the country where the traveler is
located back to the US.
Available plans can cover individuals or groups for specific periods of time
abroad and can be in effect should they be stationed abroad for an extended
period of time. There are policies for corporations to insure their personnel,
plans to cover missionaries who are on an outreach program and for those participating
in extreme sports. International travel medical insurance should be considered
for anyone traveling or living abroad.
©David M. Schmader, Solon, Ohio January, 2005
www.brownschmader.com
About the Author
David Schmader is an independent broker agent located in the Cleveland Ohio suburb of Solon, Ohio. With over 25 years of corporate finance experience he specializes in serving the individual, professional and small business markets.
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