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Author: Keenan Powell

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An Explanation of Benefit (sometimes called "Explanation of Medical Bill Payment" or "Explanation of Review") is the document that an insurance company is required to send you when it receives a bill from your health care provider.  The insurance company is required to tell you if it is going to pay the bill and if it is not, why not.  The forms are difficult to read but it is important to take the time the time to understand what the insurance company is saying because it might be screwing you.

If the insurance company is denying the bill, then it needs to explain the reason.  Frequently the company will reference a code in its explanation but doesn’t give you the codes.  If that happens, send a letter (USPS priority so you can track receipt) demanding the codes.  And keep a copy of that letter.

Read the reason for denial.   If the insurance company is wrong, then follow the procedure that the insurance company provides for appealing the decision.  Some insurance companies will spell out a particular procedure on the back side of the form and there will be deadlines.  Follow the procedure to the letter.

If your EOB doesn’t have a procedure, write to the insurance company and explain to it why it is wrong.  Again, keep a copy of the letter and track its delivery through USPS.

Sometimes, your automobile insurance company may deny payment of a bill because the bill was not coded as a motor vehicle accident.  Assuming that the bill is a legitimate cost of treating your motor vehicle accident injuries, then you need to call the billing department of your provider and explain to them the coding problem.  The billing department’s telephone number will be on the bill that they sent you.  They are generally very helpful and would be happy to do what is necessary to smooth out a problem.

Insurance companies are under an obligation to deal with you in good faith and there are several specific mandates that they are required to obey:  A person may not commit any of the following acts or practices:

  • (1) misrepresent facts or policy provisions relating to coverage of an insurance policy;
  • (2) fail to acknowledge and act promptly upon communications regarding a claim arising under an insurance policy;
  • (3) fail to adopt and implement reasonable standards for prompt investigation of claims;
  • (4) refuse to pay a claim without a reasonable investigation of all of the available information and an explanation of the basis for denial of the claim or for an offer of compromise settlement;
  • (5) fail to affirm or deny coverage of claims within a reasonable time of the completion of proof-of-loss statements;
  • (6) fail to attempt in good faith to make prompt and equitable settlement of claims in which liability is reasonably clear;
  • (7) engage in a pattern or practice of compelling insureds to litigate for recovery of amounts due under insurance policies by offering substantially less than the amounts ultimately recovered in actions brought by those insureds;
  • (8) compel an insured or third-party claimant in a case in which liability is clear to litigate for recovery of an amount due under an insurance policy by offering an amount that does not have an objectively reasonable basis in law and fact and that has not been documented in the insurer's file;
  • (9) attempt to make an unreasonably low settlement by reference to printed advertising matter accompanying or included in an application;
  • (10) attempt to settle a claim on the basis of an application that has been altered without the consent of the insured;
  • (11) make a claims payment without including a statement of the coverage under which the payment is made;
  • (12) make known to an insured or third-party claimant a policy of appealing from an arbitration award in favor of an insured or third-party claimant for the purpose of compelling the insured or third-party claimant to accept a settlement or compromise less than the amount awarded in arbitration;
  • (13) delay investigation or payment of claims by requiring submission of unnecessary or substantially repetitive claims reports and proof-of-loss forms;
  • (14) fail to promptly settle claims under one portion of a policy for the purpose of influencing settlements under other portions of the policy;
  • (15) fail to promptly provide a reasonable explanation of the basis in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement; or
  • (16) offer a form of settlement or pay a judgment in any manner prohibited by AS 21.96.030;
  • (17) violate a provision contained in AS 21.07.

AS 21.36.125(a).

If you’ve done everything that you can do to get the bill paid and the insurance company is wrongfully refusing to pay it, you can file a complaint with the Division of Insurance:  http://commerce.alaska.gov/ins/Insurance/filingAComplaint.html.

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Bike to School Day was May, 2013 and Bike to Work Day is May 17, 2013.  Approximately 1,500 people commute to work in Anchorage by bike, more in the summer.  http://www.adn.com/2010/03/20/1192613.  And with the advent of more cyclists, it’s important to keep a few things in mind:

Drivers - If you hit a cyclist, you’re going to get into a lot of trouble.  You could end up being cited by Anchorage Police, having a claim filed against your insurance and/or sued.  And that’s if the cyclist lives.  If the cyclist dies, the criminal charges could be serious.  The reason that you’re going to get into trouble is that your bigger and faster and can do more damage with your car.  As a driver of a vehicle, you have a duty of "due care to avoid colliding with other traffic."  AMC 09.16.140(B).

Your duty is greater if you observe a child.  You shall give warning by sounding your horn when necessary and shall exercise proper precaution when observing any child.  AMC 9.16.140(A).

This is especially true if the cyclist is a child.  When you see a child walking or biking on the road or near the road, it is a good idea to slow down and watch them because children tend to make sudden movements without forethought.  And if something bad happens and you weren’t exercising proper precaution, you will get into a lot of trouble.

The majority of vehicle vs bicycle accidents occur when the vehicle is stopped at an intersection waiting for traffic to clear so the driver can turn right.  Generally the driver is watching for on-coming traffic to the left and doesn’t think to check the sidewalk or bike trail for traffic coming from the right.  As a driver, you have the duty of due care which means looking both ways for traffic before entering an intersection.

If you are a driver and involved in an accident with a pedestrian or cyclist, report it to your insurance company.  You are obliged to stop, render assistance and provide your name and insurance information just as if you were involved in a collision with another car.

Cyclists - Watch for inattentive drivers.

There are a number of city ordinance which govern riding bicycles in Anchorage.  Amongst the ones most commonly violated are:

1. The duty to obey traffic control devices.  AMC 09.38.030.  When riding a bike, you are required to obey traffic control devices (lights and stop signs) as if you were driving a vehicle.

2. Riding on the wrong side of the road.  The law requires you to ride on the right edge of the roadway wherever practicable, if you are going to ride in the road.  AMC 09.38.060.  If the right side of the road is too narrow to ride safely, then you may ride on the left side of the road.  AMC 09.38.060(A)(3).

3. It is against the law to ride a bicycle on the sidewalk of a business district, AMC 09.38.070, begging the question: how are you to get to work?  I’ve never seen anyone pulled over by a police officer for riding on the sidewalk in a business district, but you should be aware that the rule is for your safety.  People pulling in and out of business driveways are not on the lookout for cyclists.  If you are hit by a car when you are riding on the sidewalk, you will be responsible at least in part for causing the collision.  The long view is that if you are responsible for causing the collision, then you will not obtain a settlement from the driver’s insurance for your medical bills.

4. When you are riding on a sidewalk or bike path, you are obligated to yield the right-of-way to pedestrian.  AMC 09.38.070.

5. When you are riding on a sidewalk or bike path, you shall give an audible signal by voice or by bell before overtaking and passing a pedestrian.

6. Bike helmets are mandatory for any person 15 years of age or younger riding in a public place.  AMC 09.38.200.  The child’s parents can be fined if the child is not wearing a helmet.

For a complete list of the applicable laws, see http://www.muni.org/Departments/OCPD/Planning/AMATS/Documents.  Search for the Adopted Bicycle Plan Appendices.

If you are riding your bike and are involved in a collision with a vehicle, get the driver’s name and insurance information, the license plate of the vehicle and photos of the vehicle damage.  Then call a personal injury attorney.  Contact Keenan Powell: keenan@keenanpowell.com, (907) 258-7663.

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RED, the Tony award winning play about American abstract expressionist painter Mark Rothko as he paints the biggest commission in the history of modern art, a series of murals for New York's famed Four Seasons Restaurant.

May 2nd, 2013 - June 16th, 2013, 7 p.m. Thurs, Fri, Saturday; 3 p.m. Sunday, Cyrano's Theatre Company, 413 D St , Anchorage, AK 99501, Local: 263-2599, Website: http://www.cyranos.org.

BLACK AND WHITE PHOTOGRAPHY WORKSHOP.  Brush up on traditional black-and-white digital photography techniques. Learn how to evaluate shades of grey, light and form in subjects to capture dynamic monochrome images. Monday through Wednesday, May 6-8, 6:30 to 8:30 p.m. http://www.anchoragemuseum.org/learn/CLASSES_adult.aspx.

ALASKA WWII REMEMBRANCE DAY.  This musical narrative is dedicated to the 70th Anniversary of the Battle of Attu and will take you on a journey through Alaska’s history during WWII. The program will include music from many cultures touched by the tumultuous time period of 1941-1945.  Alaska WWII Remembrance Day is presented by Russian American Colony Singers., May 9th, 2013 - May 11th, 2013, 7 p.m. Thursday; 2 p.m. Saturday, St. Patrick's Parish. http://alaskapac.centertix.net/eventperformances.asp?evt=1088.

FOOD TRUCK CARNIVAL.  Every Thursday, April 18th, 2013 - September 26th, 2013, 11 a.m. - 3 p.m. Chilkoot Charlie's parking lot

ARCTIC SIRENS CABARET FUNDRAISER FOR YWCA ALASKA, May 10th, 2013, 7:30 p.m., Snow Goose Theater, 717 3rd Avenue , Anchorage, AK 99503, Local: 907-245-7311, Website: http://www.arcticsiren.com.

ANCHORAGE MARKET & FESTIVAL, May 11th, 2013 - September 8th, 2013, 10 a.m. - 6 p.m., 3rd & E St. Parking Lot, 225 E Street , Anchorage, AK 99501, Local: 907-272-5634, Website: http://anchoragemarkets.com.

BEAR AWARE AT THE ALASKA ZOO, May 12th, 2013, Noon to 4 p.m., Alaska Zoo, 4731 O'Malley Road , Anchorage, AK 99507, Local: 907-341-6463, Website: http://www.alaskazoo.org/bear-aware-event.

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Not my usual topic, but I had the unhappy opportunity to review the law, and so I am sharing the benefit of my knowledge:

New vehicles:  Generally the manufacturer’s written warranty, including exclusions, will determine whether or not the dealer is responsible for repairs on new vehicles.  There is an exception, the so-called “federal emissions warranty” which is properly known as the Clean Air Act section 207 and codified at 42 USC 7541: http://codes.lp.findlaw.com/uscode/42/85/II/A/7541.

Amongst other warranties, 42 USC 7541 states that the manufacturer must warranty catalytic converter, electronic emissions control unit, and onboard emissions diagnostic device.  These components are warrantied for a period of 8 years or 80,000 miles.

GM in particular seems to be having problems with catalytic converters.  As long as you have properly maintained your vehicle (keep records), then GM is required to replace it.  Take your vehicle to an authorized dealer and demand repair.

Used vehicles:  Used vehicle service warranties are established by Alaska law.  See Alaska Department of Law Consumer Protection Unit’s website: http://www.law.alaska.gov/department/civil/consumer/4545130.html.

Amongst other duties, a shop must provide a written repair order, a written estsimate, may not exceed the charges in the estimate without the customer's agreement, may not charge excessively, must return parts if requested by the customer when the repair order is place, and provide a written invoice when the repairs are completed.

Moreover, a shop may not refuse to release a vehicle if it is charging more than estimated without consent or charging excessivley.

If you are having a problem with a dearlership or a shop, you can file a complaint with the Consumer Protection Unit:  http://www.law.alaska.gov/department/civil/consumer/cp_complaint.html.

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"An employee may not be required to pay a fee or charge for medical treatment or services provided under this chapter."  AS 23.30.097(f).

An employee never has to pay for his medical treatment for a Workers Compensation Claim.  AS 23.30.097(f).  If you were made to pay for any of your treatment then you need to submit the proof of the charge and payment to the insurance company for reimbursement.  Be sure that you keep a copy for your own files of the proof of payment and the date upon which you sent it to the insurance company for reimbursement.  There are two ways to prove that you submitted the payment:

1. You can hand carry the payment to the insurance company and ask the receptionist to sign and date your copy of the document, or

2. You can mail it priority mail.  You will be given a tracking number by USPS.  After the mail is delivered, go to the USPS website and print off the proof of delivery.

The reason that is important to keep proof of your submission is that you are entitled to a 25% penalty if the insurance company is late reimbursing you.  For more information: http://keenanpowell.com/faq-wc.html.

If the insurance company controverts you and refuses to pay the medical bills, you are not required to pay the bills.  AS 23.30.097(f).  However the doctors are not required to treat you if they are not paid under most circumstances, so you probably won’t receive treatment.

If you have health insurance or are eligible for Medicaid or Medicare, the providers can bill those entities while you are sorting out the Workers Compensation case.

If you do not want to file a claim for payment of medical benefits, then the providers are entitled to file a claim directly.

Call:  Keenan Powell 258-7663.  E-mail:  keenan@keenanpowell.com.

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It snowed again.  A particularly nasty wet snow making for icy roads.  And we had lots and lots of  accidents yesterday: 164 by 9:30  PM according to Anchorage Daily News.

More big news:  Anchorage Police Department has a new policy.  It won't file a police report unless the officer thinks that the accident caused an injury.  So you can't rely on the police officer to take the witness' names and phone numbers, much less the name of the other drivers involved.  You need to do that yourself.

Not only that, APD probably won't take photos at the scene.  Take photos on your cell phone.  Be sure to get the license plate number of the other car.  Be sure to get photos of damage to the other vehicle as well as the  scene of the accident.  Why do you ask?  Because the other driver could claim that you caused the accident or his damage was minor and to prove your case, you will need  photos of his car to prove how his car impacted yours and how severe the impact was.

After an accident, the law requires you to stop, contact the other drivers or pedestrians involved, exchange name and insurance information, and render assistance to injured persons.  For your own protection, get the names and phone numbers of all witnesses, photograph the scene and the vehicles involved in the accident.

Go to the hospital if you need medical attention.

Then, call you insurance company and report the accident.  And then call the other driver's insurance company to report it as well.  You can google the insurance company and obtain a number to call.

The next day, follow up with any medical providers to whom you were referred by the emergency room.  Or if you didn't go to the hospital, but you're starting to hurt, go to your doctor or to a minor emergency clinic.

Don't expect the other driver's insurance company to pay your medical bills.  Even if the insurance company accepts  liability, it will wait until the end of the case and sometimes it will send the medical records to its own doctor to evaluate them, to see if they have a reason not to pay those bills.

One common defense  the insurance  company will raise is to claim that chiropractic care was excessive and that in a simple whiplash case, the injured person would recover in 6-12 weeks even without chiropractic treatment.  It's called the Quebec defense.   If you have been seeing a chiropractor for 3 months or more and  you aren't better, you should check in with a medical doctor to get his opinion as to whether your chiropractic  care is appropriate and also to find out if your injury is more severe than chiropractic care can treat.

How do you pay for the medical bills  before your case is settled?  Your medical payments benefits which you purchased with your automobile liability insurance should be billed first.  For more information regarding automobile  liability insurance, look at "Car Accidents and P.I." page.

If you don't have medical payment benefits, bill your group health insurance provided by your employer.

If you don't have  group health insurance, you'll need to pay your bills directly, find a sliding fee scale clinic or  enter into an agreement with the provider to pay him when the case is settled.

For more information, contact Keenan Powell:  keenan@keenanpowell.com.  Phone: 907 258 7668 or 888 368 5678.

 

 

 

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Don't forget First Friday!  Artique will host First Friday on April 5 from 5-7 PM with new works from local artists on the theme of birds.  http://www.artiqueltd.com/.  Check out Linda Lyon's fabulous painting that will be in the exhibit on my FB:  https://www.facebook.com/keenanpowellak.

Artic Rose is featuring Alaska State Parks and Arts in the Parks program and is accepting submissions.

Comedy Improv, Fridays 8 PM.  Snowgoose.

Dead Man’s Cell Phone.  March 29 through April 21.  Thursdays to Saturdays 7 PM, Sundays 3 PM.  Cyrano’s.

The Circuitous Route of a Raven.  A lunch time talk given by Don Reardon, author of The Raven’s Gift, about his experiences in publishing.  April 4, 2013 11:30 AM  to 1 PM.  Kinley’s Restaurant.

April First Tap with Brett Dennen, folk/pop singer.  Bear Tooth.  Doors open at 8 PM.

Pirates of Penzance.  April 5 through April 7.  Friday through Saturday 8 PM, Sunday 4 PM.  PAC.

The Step Crew.  Irish step dancing.  April 13 at PAC.

Mosiacs workshop.  April 13-14.  Saturday 10-4, Sunday 12-2.  Museum.  If you like mosiacs, there are ongoing classes in the Valley: http://arcticmermaidmosaics.com/.

Anchorage Symphony Orchestra Season Finale.  April 20 8 PM.  PAC.

Montery Jazz Festival on Tour.  April 28 7:30 PM PAC.

For more information, see http://www.anchorage.net/events.

 

 

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Snow: Pretty in a snowglobe.  Not so pretty when you’re trying to drive somewhere.

 

Because of Alaska’s unique climate, and all the snow, quite a bit of law has evolved since Statehood regarding who is responsible for clearing the snow, who is responsible for making the streets, sidewalks and parking lots safe to drive and walk on and when that person is liable if someone is injured because of snow or ice.

 

Snow and ice issues are found in landlord-tenant law, negligence claims against landowners, claims against drivers, claims against the State of Alaska for negligent highway maintenance as well as common in Workers Compensation claims.

 

A residential landlord is responsible for clearing snow and ice and for making the premises safe for his tenants.  Simply leaving a bucket of ice melt near the sidewalk is not good enough.  If someone slips and falls on his property, a tenant or a tenant’s guest, he will be liable for that person’s medical bills, lost wages, and pain and suffering.

 

Drivers must be more careful in snowy and icy conditions.  Even if they are driving the speed limit, the speed limit may be too high for the conditions.  Drivers need to slow down and be particularly careful in intersections.  If a driver causes an accident because he is driving too fast for the conditions and loses control of his car, slides into another lane, rear ends someone, he will be liable.

 

Business owners are responsible for maintaining their parking lots and sidewalks so that it is safe for their patrons to drive and walk on.  The first case in Alaska establishing this rule was a lawsuit against Carr’s.

 

The City is responsible for snow removal in Anchorage and would be liable if conditions were so bad that no one could drive safely or if the City left a berm which blocked line of sight at an intersection and the City’s actions were unreasonable.

 

So too is the State responsible for snow and ice removal on the highways.  Juries have held the State accountable when an accident was caused by the conditions regardless of how careful the drivers were.

 

In Workers Compensation, if you are injured for any reason at work, the Employer’s insurance company is liable for you benefits.  Generally the “coming and going” rule says that if you are hurt on your way to work or on the way home, then you are not entitled to Workers Compensation benefits but if you are required to park in the Employer’s parking lot and must walk in a designated area owned by the Employer to reach your work place and you slip and fall on an accumulation of ice and snow, then you will be entitled to Workers Compensation benefits.

 

The bottom line is:  if you are hurt because of the conditions, you will need to prove it.  Take pictures as soon as possible. Then contact an attorney.

 

For more information, see the FAQ page:  http://keenanpowell.com/faq-mva.html

 

To contact Keenan Powell, e-mail:  keenan@keeenanpowell.com.

 

 

 

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Workers Compensation is a whole new world and if you’ve never dealt with it before, you might feel like you just fell into the Land of Oz.

Many Employees that I meet think that they have been dealing with the Workers Compensation Board when actually they have been talking to an adjuster for an insurance company. So when the adjuster tells them something like"Workers Compensation will not pay for that surgery", the Employee believes that it’s the law that is preventing them from getting the surgery whereas the truth is that it’s an insurance company trying to increase it’s profits by denying the Employee’s benefits.

So who is "Workers Compensation"?  The Division of Workers Compensation is a part of the State of Alaska’s Department of Labor.  http://labor.state.ak.us/wc/home.htm.   It has a director in Juneau and offices in Anchorage, Fairbanks and Juneau.   In each of the offices, there hearing officers who manage the files.  In the Anchorage office, there are legal technicians who are available to talk to injured Employees.  If a case goes to a hearing, it will be decided by Board members of which there are three: a hearing officer who is an employee of the Division, and two members of the public appointed by the governor.  One of the members is from labor and one is from management.   These are the people who decide what an Employee’s rights are.

There is usually an insurance company involved in your case because all employers in the State of Alaska are required to carry workers compensation insurance unless they are approved as self-insured employers.  If they are self-insured, they will hire an adjusting firm to handle the files.  The adjuster does not work for the State.  The five largest insurers in Alaska are: Alaska National, State of Alaska, Liberty Northwest, Commerce & Industry, and Liberty Insurance.  http://labor.state.ak.us/wc/forms/2011AR.pdf.

It is important to remember that when you are talking to someone from the insurance company, they do not speak for the Board.  They represent the insurance company who pays their salary and their job is to save the insurance company money.   The adjusters have orders from the supervisors on how to handle claims, they have very little discretion.  So there is no point in arguing with them.

If you have any questions regarding your case, you can go to the Workers Compensation office and talk to a legal technician and you can consult with an attorney.   The Law Office of Keenan Powell provides free consultations regardless of whether or not you have been controverted.   To contact Keenan Powell, use the contact form on this page or call 258-7663.

For more information about Workers Compensation, see:  http://www.keenanpowell.com/faq-wc.html.

mailto:keenan@keenanpowell.com.

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When the employer is determined to be "medically stable", then he or she is entitled to a Permanent Partial Impairment (PPI) rating.

"Medically stable" means that there is no objective measurable improvement.  Medical stability is presumed in the absence of objectively measurable improvement for a period of 45 days however that presumption can be rebutted.

The PPI rating is determined by a physician who is specifically trained to conduct PPI ratings.  He examines the Employee and reviews medical records and then makes his determination based upon the American Medical Association Guidelines to the Evaluation of Permanent Impairment.

When the physician assesses a certain PPI rating, he will state that the Employee has a per centage of whole body disability.  The whole body figure used in Alaska in $177,000.  Thus if the physician says that the Employee has a 10% PPI rating, then the Employee should be paid 10% of $177,000 or $17,700.

There is a lot of room for disagreement in this process.   Frequently the insurance company will hire an doctor to perform an Employer Medical Evaluation (EME) and that doctor concludes that the Employee is medically stable but the treating physician say that he isn’t, that he needs more treatment to improve.

Another area of disagreement is when the Employee became medically table.  Sometimes the EME will conclude that the Employee was medically stable months before the evaluation but the treating physician assesses a different date.  The reason that is a problem is that if the Employee was drawing Temporary Total Disability during the period time after which the EME said that he is medically stable, the insurance company is going to want that money back.

The obvious area of disagreement is the PPI rating itself.  The EME will often conclude that the rating is very low, claiming that there is pre-existing degenerative changes and/or that the Employee was malingaring (faking) the extent of his disability.

When these disagreements come up, the Employee is entitled to a Second Independent Medical Evaluation (SIME).  A SIME is an evaluation by physician chosen by the Board.  The insurance company pays for the SIME and if the Employee needs to travel to the doctor, the insurance company is required to pay for the travel as well as time missed from work.

For more information, see http://www.keenanpowell.com/faq-wc.html

Contact Keenan Powell through the contact form or call: 258-7663.  Toll free: 888-368-5678.