Coverage Issues. General Agent may refer any coverage question, denial of liability, or Policy limit demand to Company for final determination by Company concerning such issues. General Agent shall notify and provide a copy of any applicable claim file to Company within 30 days of determination that a claim has:
Coverage Issues. SRM administers IDPN therapy to chronic dialysis patients who suffer from severe gastrointestinal malfunctions. IDPN therapy was provided by Homecare prior to its divestiture. After 1993, Medicare claims processors sharply reduced the number of IDPN claims approved for payment as compared to prior periods. NMC believes that the reduction in IDPN claims represented an unauthorized policy coverage change. Accordingly, NMC and other IDPN providers pursued various administrative and legal remedies, including administrative appeals, to address this reduction. In November 1995, NMC filed a complaint in the U.S. District Court for the Middle District of Pennsylvania seeking a declaratory judgment and injunctive relief to prevent the implementation of this policy coverage change. (National Medical Care, Inc. v. Shalala, 3:CV-95-1922 (RPC)). Subsequently, the District Court affirmed a prior report of the magistrate judge dismissing NMC’s complaint, without considering any substantive claims, on the grounds that the underlying cause of action should be submitted fully to the administrative review processes available under the Medicare Act. NMC decided not to appeal the Court’s decision, but rather, to pursue the claims through the available administrative processes. NMC was successful in pursuing these claims through the administrative process, receiving favorable decisions from Administrative Law Judges in more than 80% of its cases. In early 1998, a group of claims which had been ruled on favorably were remanded by the Medicare Appeals Council to a single Administrative Law Judge (the “ALJ”) with extensive instructions concerning the review of these decisions. A hearing was scheduled on the remanded claims to take place in July, but later postponed until October 1998. Prior to the July hearing date, the United States Attorney for the District of Massachusetts requested that the hearing be stayed pending resolution of the OIG Investigation, on the basis that proceeding could adversely effect the government’s investigation as well as the government’s efforts to confirm its belief that these claims are false. Prior to the ALJ issuing a decision on the stay request, the U.S. Attorney’s Office requested that NMC agree to a stay in the proceedings in order to achieve a potential resolution of the IDPN claims subject to the OIG Investigation as well as those which are subject to the administrative appeals process. NMC agreed to this request, and together with the U.S. At...
Coverage Issues. General Agent may refer any coverage question, denial of liability, or Policy limit demand to Company for final determination by Company concerning such issues. General Agent shall notify and provide a copy of any applicable claim file to Company within 30 days of determination that a claim has: (a) the potential to exceed the authority limit set forth in Article 21.2 of this Agreement; (b) a coverage dispute, or any unusual circumstances or large loss possibilities or any issues that would be required to be reported to Reinsurers under the Affiliated Reinsurance Agreements, Quota Share Reinsurance Agreement, or Excess of Loss Reinsurance Agreement; (c) a demand in excess of Policy limits; (d) allegations of bad faith, violations of any deceptive trade practice acts, or any other Regulation; (e) resulted in a legal action being instituted against General Agent, an Agent, a Broker or Company; (f) arisen from or caused a complaint to be filed with any regulatory authority; (g) arisen from or caused an inquiry from any regulatory authority, including, but not limited to, any insurance department, with respect to any loss, even if the inquiry does not arise from a complaint; 25 Managing General Agency Agreement Effective July 1, 2006 (h) a significant coverage dispute that may be denied; (j) been open for more than six months or involves an allegation of extra contractual damages; (j) a minor claimant, unless it is certain that the amount of the loss related to a minor is less than $[**]; or (k) been closed by payment of an amount established by Company. General Agent shall, if requested by Company, send a copy of each and every claim to Company within 24 hours of General Agent’s receipt of such claim as described in Article 21.2 of this Agreement. To the extent possible, such transmission of claims shall be by electronic means, overnight mail or facsimile to Company at 0-000-000-0000 or such other telephone number as Company may specify. 21.7.
Coverage Issues. This plan only covers Amish workers. It does not cover non-Amish workers. An Amish employer may employ both Amish workers and non-Amish workers. Accordingly, if such an Amish employer participates in the Amish Small Business Aid plan, it must still provide coverage for its non-Amish workers. For an insurer covering such an employer, to properly set up the policy, it appears an appropriate method could be attaching the Partners, Officers and Others Exclusion Endorsement (WC 00 03 08). In the endorsement schedule of excluded workers, it could display the words “Amish employees covered under the Amish Small Business Aid.” Issues & Answers Because this agreement is new, and in consultation with the Board, we have attempted to anticipate issues and questions which may arise and provided answers (please see below).
Coverage Issues
