MAY 7, 2012 | VOL. 90, NO. 9 WEST REGION Remarkable
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WEST N12 On The Cover Special Report: 2012 Super Regional Inside This Issue P/C Insurers™
May 7, 2012 • Vol. 90, No. 9 • West Region
14 20 32 N32
NATIONAL COVERAGE WEST COVERAGE IDEA EXCHANGE N10 Insurance Jobs Outlook: 8 Meteorologist: Tornado Near 40 Cybersecurity Disclosure Getting Better, Region Stockton, Calif., not Unusual Obligations Raise Insurance by Region Coverage Questions 14 Replacement Costs Battle on N12 Special Report: 2012 Super the Road to Somewhere N1 Minding Your Business: Oak & Regional P/C Insurers™ Schoeffler 18 Path Set for ACOs in N20 Spotlight: AAMGA’s Chaffin Healthcare Delivery N2 General Ledger Accounting and Outlines Ingredients Premium Transactions for Success 20 West Insurance Employment: California Job Market to Stay N32 Closing Quote: Industry’s Role N22 New Ventures Ready and Soft in Preventing Contractor Fraud Waiting for Economy, Market to Turn 26 U.S. Tells Industry to Further Test Safety of N26 2012 Premium Finance Nanotechnology Products Directory 32 California Workers’ Comp Reform Taking Shape – Again 38 Current Market Not Yet DEPARTMENTS a ‘Classic’ Hard Market: P/C Executives 6 Opening Note 9 Declatrations 9 Figures 10 Business Moves 14 People
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EDITORIAL Editor-in-Chief Andrea Ortega-Wells | awells@insurancejournal V.P. Content Andrew Simpson | [email protected] Opening Note East Editor Young Ha | [email protected] Southeast Editor Michael Adams | [email protected] South Central Editor/Midwest Editor Stephanie K. Jones | [email protected] West Editor Too Old to Care Don Jergler | [email protected] International Editor Charles E. Boyle | [email protected] ut the following in the “I’ll be dead or too old to care” category. ClaimsJournal.com Editor Denise Johnson | [email protected] Drivers will save $68 billion in fuel costs when the Obama MyNewMarkets.com Associate Editor Amy O’Connor | [email protected] Administration’s 54.5 miles-per-gallon standard is fully implement- Columnists Catherine Oak, Bill Schoeffler ed in 2030, according to a report by the Natural Resources Defense Contributing Writers Council.P Barry Koestler, Chris Marinescu, Robert Passmore, Joseph Petrelli The 54.5 mpg by 2025 standard, if finalized, would double today’s average SALES V.P. Sales & Marketing Julie Tinney (800) 897-9965 x148 fuel efficiency, saving drivers $4,400 over the life of the vehicle, the report [email protected] West Dena Kaplan (800) 897-9965 x115 shows. That’s if the goal is reached by 3030, and if the administration and [email protected] South Central Mindy Trammell (800) 897-9965 x149 NRDC scientists are correct in their assumptions. [email protected] Rarely do projects get done on time. And plans that make sweeping Midwest Lauren Knapp (800) 897-9965 x161 [email protected] change — for better or worse — seem to take even longer. Southeast Howard Simkin (800) 897-9965 x162 [email protected] I recall the construction of the Century Freeway, Interstate 105 in Southern East Dave Molchan (800) 897-9965 x145 [email protected] California, and being a youth in the back seat of a car and the adult driver New Markets Sales Manager Kristine Honey | [email protected] would point and say “Look there, that’s going to be a freeway someday.” Classified Advertising (800) 897-9965 x125 Planning on the 105 began in [email protected] the 1960s. It opened in 1993. California’s high speed MARKETING/NEW MEDIA Marketing Administrator Environmentalists, communi- rail is another dream that, Gayle Wells | [email protected] Advertising Coordinator ty opposition and earthquakes Erin Burns | [email protected] when it comes to fruition, (619) 584-1100 x120 were among reasons given for New Media Producer the long completion time of most people reading this Bobbie Dodge | [email protected] Videographer/Editor a much needed highway that will long in the tooth – Matt Tolk | [email protected] takes drivers from the transit DESIGN/WEB and then some. Vice President/Design stop for the Green Line to Los Guy Boccia | [email protected] Angeles International Airport. Vice President/Technology Joshua Carlson | [email protected] But similar arguments can be made for all projects. Speaking of the Green Design and Marketing Executive Derence Walk | [email protected] Line, planning for Los Angeles County’s Metrorail system began in the 1970s Art Director Jamie Bethell | [email protected] and it wasn’t until 1990 that the first line was in operation. And don’t expect Web Developer Jeff Cardrant | [email protected] the Green Line to be able to take you all the way to LAX until 2028. Web Developer While people in the L.A. area are now able to take advan- Chris Thompson | [email protected] tage of the 105 and the Metro, I’m sure there were many area tax- IJ ACADEMY OF INSURANCE Director of Education paying residents who have long passed who would have liked to Christopher J. Boggs | [email protected] Online Training Coordinator have been served by these transportation options. Barbara Dooley | [email protected] California’s high speed rail is another dream that, when/if ADMINISTRATION it comes to fruition, most people reading this will be long in the Chairman Mark Wells tooth — and then some. As a reporter in the desert northeast Chief Executive Officer Mitch Dunford of L.A. I covered planning on the route expected to run from Accounting Manager Francisco to L.A. That was in the late 1990s, and cost estimates Megan Sinclair | [email protected] of around $30 billion were being tossed out for an efficient and FOR QUESTIONS REGARDING SUBSCRIPTIONS: speedy magnetic levitation train. Despite voter approval of more Call: 856-380-4176 or a $9 billion-plus bond, the project is still being debated, and it’s You may subscribe or change your address online at one that would provide a more conventional and slower moving train than insurancejournal.com/subscribe
the maglev train under consideration early on. Insurance Journal, The National Property/Casualty Magazine (ISSN: 00204714) is published semi- monthly by Wells Publishing, Inc., 3570 Camino del Rio North, Suite 200, San Diego, CA 92108-1747. In April the California High-Speed Rail Authority passed a revised business Periodicals Postage Paid at San Diego, CA and at additional mailing offices. SUBSCRIPTION RATES: $7.95 per copy, $12.95 per special issue copy, $195 per year in the U.S., $295 plan that will provide a high speed train “within a decade” at a cost of $68.4 per year all other countries. DISCLAIMER: While the information in this publication is derived from sources believed reliable and is subject to reasonable care in preparation billion. Unlikely on either count. and editing, it is not intended to be legal, accounting, tax, technical or other professional advice. Readers are advised to consult competent professionals for application to their particular situation. Copyright 2012 Wells Publishing, Inc. All Rights Reserved. Content And I’ll be too old to care. Don Jergler may not be photocopied, reproduced or redistributed without written permission. West Editor Insurance Journal is a publication of Wells Publishing, Inc. POSTMASTER: Send change of address form to Insurance Journal, Circulation Department, PO Box 9049, Maple Shade, NJ 08052
ARTICLE REPRINTS: For reprints of articles in this issue, contact Rhonda Brown 6 | INSURANCE JOURNAL-WEST REGION May 7, 2012 at 1-866-879-9144 ext. 194 or [email protected]. Visit insurancejournal. com/reprints for more information.
WEST COVERAGE News & Markets Meteorologist: Tornado Near Poll: Northwest Residents Stockton, Calif., not Unusual Rely on Vigilance to Protect
he National Weather Service says the tornado that struck Identities Tfive miles outside of Stockton, Calif., last month was not unusual for the time of year. ost Northwest residents are concerned about the threat The twister on farm- Mof identity theft, but a majority rely on their own vigi- land near Interstate 5 left lance to protect themselves from fraudulent activity against a path of damage about a their personal information, a poll from Seattle, Wash.-based mile long. The Record of PEMCO Insurance shows. Stockton reported that it The poll shows less than one-fifth of drivers in the shredded a wood-frame Northwest — 18 percent in Oregon and 16 percent in shop, tipped over a big- Washington — say they subscribe to an identity-theft protec- rig trailer and sent shards tion service. of aluminum siding The insurer said a majority in both states engage in other across more than an acre identity-protecting behaviors, such as installing security soft- of land. ware, using a shredder to destroy sensitive documents, and National Weather removing personal identification from wallets and purses. Service Meteorologist A nationwide study cited by Washington State Attorney Stefanie Henry says it also took the shingles off the roof of a General Rob McKenna states that while the number of iden- home. tity theft victims has decreased in recent years, identity fraud There were no reports of injuries. Henry says California is costing consumers more out-of-pocket expenses. The mean averages about eight tornadoes a year. out-of-pocket cost due to identity fraud increased 63 percent from $387 in 2009 to $631 per incident in 2010, according to @2012 Associated Press. All Rights Reserved. the study. UC, FBI Reach Settlement Earthquake Hazard in Berkeley Raid Suit in Washington to Be Studied
he FBI and University of California have agreed to pay he federal government is going to take another look T$100,000 and destroy computer files to settle a law- Tat the potential earthquake hazard at Hanford in suit stemming from a raid on the offices of two groups in Washington. Berkeley. The seismic assessment will update the Department of Long Haul Inc. and East Bay Prisoner Support were raided Energy’s last comprehensive analysis in 1996. in 2008 by federal agents and university police after authori- The Tri-City Herald reported new understanding of seismic ties said threatening messages to animal researchers at the faults in the Pacific Northwest will inform the new assess- University of California, Berkeley had been sent from a com- ment. puter at the storefront the two groups occupy. The largest earthquake record- Long Haul has public computer terminals and meeting ed in the region was a magni- rooms that attract people involved in left-wing causes. tude-5.7 earthquake 72 miles from Lawyers for Long Haul say officers seized all 14 of the Hanford at Milton-Freewater in group’s computers. No evidence of criminal wrongdoing was 1936. That’s according to data found. collected for the design of the The San Francisco Chronicle reported that the university Hanford vitrification plant. will pay three-fourths of the settlement. UC Berkeley offi- Eastern Washington also was hit by an earthquake with an cials maintain that their officers acted properly. estimated magnitude of 7.3 in 1872 near Lake Chelan.
@2012 Associated Press. All Rights Reserved. @2012 Associated Press. All Rights Reserved.
8 | INSURANCE JOURNAL-WEST REGION May 7, 2012 www.insurancejournal.com Declarations Employee Relief State Fund Discipline Kriedler Commish “An employer must relieve the employee of “The competitive market continues to “Me serving so long is particularly good for all duty for the designated period, but need underprice business. We are maintaining an insurance commissioner, who have a not ensure that the employee does no work.” our pricing discipline, and as a result we fairly short lifespan on average. At the end — Associate Justice Kathryn Werdegar wrote tend to lose business when others under- of this term I will have 12 years, and that’s for a unanimous California Supreme Court ruling price it.” two more than any insurance commissioner late last month in a decision that allows part of a — State Fund CFO Dan Sevilla, explain- in the country.” class-action lawsuit over employee breaks against ing California’s largest workers’ compensation — Washington State Insurance Commissioner Brinker International Inc. to proceed. The court insurer’s year-over-year drop in premiums from Mike Kreidler following his announcement he’s ruled employers only have to provide meal periods 2010 to 2011. seeking a fourth term in office. to workers, not make sure employees actually take them. J.D. Power “Repair times have also increased slightly from the last quarter. This, in addition to custom- ers waiting longer for a more convenient time, or the weekend, to bring their vehicle to the repair shop, has contributed to the overall lower satisfaction scores.” — Jeremy Bowler, senior director of the insurance practice at J.D. Power and Associates, which released its 2012 U.S. Auto Claims Satisfaction Study — Wave 2 showing overall customer satisfaction for auto claims has dropped the lowest level in three quarters. Figures 2,800 10,000 BMWs are being recalled by the Acres of forested area in car maker because a circuit board Lake Tahoe in California can overheat and cause a fire. The will be thinned by the U.S. recall covers some 2011 and 2012 Forest Service in an effort models of the 5-Series, 5-Series to reduce fuel for poten- Gran Turismo, 6-Series convertible, tially catastrophic wildfires. 7-Series, X5 SAV and X6 SAV. Pending since 2004, the project won final approval last month. $ 600,000 $200,000 Is the limit of Colorado’s liability under state law for Is what Beth Fischer’s medical bills a wildfire apparently started have reportedly amounted to after by a Colorado Forest Services she suffered a dog bite at the base prescribed burn that killed of Aspen Mountain in Colorado last three people, consumed 4,140 year. Her attorneys have filed a law- acres, destroyed 25 structures suit against Aspen Skiing Co. and and forced the evacuation of the dog’s owners. 900 homes.
www.insurancejournal.com May 7, 2012 INSURANCE JOURNAL-WEST REGION | 9
WEST COVERAGE Business Moves have collaborated to provide insurance ers looking to save money on their services for its members. California contractors insurance. Under the agreement, Zurich in North America will provide AGC-CA Blue Cross members with insurance products for Blue Cross and Blue Shield of workers’ compensation, general liabil- Montana along with Blue Cross of ity, auto and property coverages, as Idaho are buying an Idaho company well as comprehensive safety and risk that provides health products and management services. employee-benefit administration ser- AGC represents more than 1,000 con- vices and merging it with a similar struction companies and construction Montana company. related firms throughout California. The insurance companies have AGC members represent some of the acquired Peak 1 Administration of state’s smallest business enterprises to Coeur d’Alene, Idaho, and merged it some of the nation’s largest construc- with Blue Cross subsidiary Insurance tion companies, with annual construc- Coordinators of Montana, which is tion volumes ranging from less than based in Helena. $100,000 to more than $100 million. The Independent Record reported the SIAA AGC members perform the majority company will operate under the name Hampton, N.H.-based Strategic of non-residential construction, and of Peak 1 Administration. Insurance Insurance Agency Alliance has signed build the state’s highways and bridges, Coordinators serves customers in nine new members in the Western office buildings, hotels, shopping cen- Montana, Idaho, Wyoming, Washington United States. ters, plants, refineries and manufactur- and Oregon. The new members include: ing facilities, as well as schools, colleges Officials declined to discuss the pur- • Farling Insurance Agency of and universities, hospitals, retirement chase price. Litchfield Park, Ariz. homes and health care facilities. Peak 1 President Dan Crawford says • Baldrica & Company of Colorado the merger allows them to increase the Springs, Colo. California Contractors Insurance services they offer and expand the area • Galli Insurance Agency of Jackson, CA-ContractorInsurance.com has they serve. Calif. been launched for California con- • SVIG Insurance Center of San tractors to go to for information on PPIB Marino, Calif. insurance issues facing their business. Professional Program Insurance • Alive Insurance Services of El The website brings information, tips, Brokerage of Novato, Calif. has formed a Cerrito, Calif. products, and expert advice to help new senior/home health care program. • Nevada Docs Agency of Las Vegas, California contractors understand and This program includes, but is not Nev. protect their business with insurance limited to the following: nurse regis- • Solid Gold Insurance Agency of policies. try, healthcare staffing, adult daycare, Pasadena, Calif. CA-ContractorInsurance.com fea- medical director, long term care, house- • Sorensen, Lewis and Associates of tures descriptions of the coverages keeper, sitter, host home, live-in com- Richfield, Utah California contractors and small busi- panion, assisted living, group home, • Risk Managers Insurance of Salt nesses need to protect their company residence manager, hospice care and Lake City, Utah assets. ContractorInsurance.com breaks e-health. Since it’s inception in 1995, SIAA has down the laws and regulations into Coverage is also available for most signed over 4,000 new members. SIAA simple forms by coverage, and sorts individuals (including doctors) within is focused on the creation, retention through the details of workers’ com- this industry needing their own per- and growth of the independent insur- pensation, general liability and small sonal coverage or for the entity. ance agency distribution system. business bonds. The policy can include professional CA-ContractorInsurance.com pro- liability, general liability, sexual mis- Associated General Contractors of vides California workers’ compensation, conduct, HNOA, privacy, property and California, Zurich California liability insurance, California other ancillary coverage lines. Limits The Associated General Contractors contractors bond and employee leas- are available up to $5 million with of California (AGC-CA) and Zurich ing products to small business own- minimal deductibles.
10 | INSURANCE JOURNAL-WEST REGION May 7, 2012 www.insurancejournal.com ROCK-SOLID FINANCIAL STRENGTH SUPERIOR CLAIMS SERVICES UNRIVALED CUSTOMER SUPPORT INNOVATIVE RISK FINANCING UNDERWRITING ONE RISK AT A TIME
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WEST COVERAGE People
Renton, Wash.-based Bell-Anderson Agency Inc. Health for eight years, will now focus on the Next Step named Steven J. Tanta chief financial officer. Medical Advisory Program as its medical director. Tanta joined Bell-Anderson in 2009 as a sales executive. Benner joined EK Health in 2011 as medical products Bell-Anderson is one of the largest regional insurance business development officer. He came from Kaiser agencies in the Pacific Northwest. Permanente. EK Health Services provides workers’ compensa- Cigna Corp. named Kim Bimestefer president and tion case management, utilization and peer review and Steven Tanta general manager for its Mountain States region, including Medicare set aside services to insurance companies, Colorado, Wyoming, Utah and New Mexico. employers, for-profits and public entities. Bimestefer will be based in Denver. She will serve as the senior leader for Cigna’s operations in the region. Global law firm Mayer Brown named veteran insur- Bimestefer has more than 25 years of experience in the ance regulatory advisor James R. Woods as a partner benefits industry. Most recently, she served as president of and a co-leader of the global Insurance Industry Group. Cigna’s Taft-Hartley and federal business segment. She will Also a member of Mayer Brown’s corporate and securi- continue in this role in addition to her leadership of Cigna’s ties practice, Woods will divide his time between the operations in the Mountain States. firm’s offices in Palo Alto, Calif., and New York. Kim Bimestefer Previously, he was a partner at Dewey & LeBoeuf, Encino, Calif.-based NAS Insurance Services named Jill where he served as co-chair of that firm’s global insur- Linhardt as senior vice president of claims. ance industry sector practice. Linhardt has been with NAS since 1994 and is a princi- Woods has more than 35 years’ experience representing pal. An attorney by training, she began as an underwriter insurers and insurance-related entities. with NAS and moved to the cliams in 2000. During the Woods is general counsel to The Surplus Line past 12 years, she has served as vice president of claims, Association of California, and to the Worldwide Broker overseeing the department, including coverage evaluations, Network. communications with attorneys, insureds and reinsurance He also represents the Insurance Information Institute Jill Linhardt clients. and the Insurance Industry Charitable Foundation on a NAS is an independent underwriting manager of spe- pro bono basis. cialty insurance with full binding authority to underwrite on behalf of Lloyd’s of London and other carriers. Pauline Bareno joined Calabasas, Calif.-based surplus lines broker Maverick Commercial Insurance San Jose, Calif.-based EK Health Services, a national Services as senior vice president. workers’ compensation managed care firm, has promoted Bareno has more than 30 years of property/casualty Dr. Douglas Benner to chief medical officer. insurance experience, including an underwriting and As CMO, Benner is responsible for leading the opera- marketing background. Douglas Benner tional management of EK Health’s physician services and Her experience includes insurance companies, retail medical staff administration. and wholesale brokerage specializing in large workers’ Dr. Richard Thompson, who has been the CMO at EK compensation insurance programs.
12 | INSURANCE JOURNAL-WEST REGION May 7, 2012 www.insurancejournal.com some things are just Better Together.
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WEST COVERAGE News & Markets Replacement Costs Battle on the Road to Somewhere
By Don Jergler
teve Young was somewhat Supbeat when he was asked what he thought about the outcome of a long-brewing legal battle between three insurance associations and the California Department of Insurance. That upbeat attitude is because a court of appeals accepted his associa- tion’s amicus brief last month. That may sound a bit trivial, but Young sees it as a signal there’s at least a slight chance the group will have its day in court sooner rather than later. Young, vice president and gen- eral counsel of Insurance Brokers & Agents of the West, applauded the Second District Court of Appeals action in granting IBA West’s request to file an amicus brief in the litigation over replacement cost regulations that deal with and present to consumers has the authority to go after under- were successfully pushed through the replacement costs on homeowners’ writing on this, his authority could be courts by the California Department insurance policies last year, it touched unbridled.” of Insurance last year. off a legal battle between the three In January, a Los Angeles County In April IBA West filed the brief, associations and CDI attorneys. Superior Court judge denied a motion a request to support the petition While CDI argues the regulations for judgment on the pleadings for writ of mandate filed by the were necessary to protect homeown- brought by the three associations . It is Personal Insurance ers, the groups that denial that the plaintiffs and IBA Federation of ‘If the commissioner believe CDI and West are asking the state appellate California and has the authority to Jones overstepped court to overturn. the Association of their authority, While the court’s acceptance of California Insurance go after underwriting and that this move the amicus brief doesn’t necessarily Companies chal- on this, his authority could be an inroads indicate how it will evaluate the writ lenging the legality could be unbridled.’ to enabling the of mandate filed by the groups for a of the replacement regulators to wield speedy appeal, Young took the accep- cost regulations. a broader authority over more than tance as a good sign. The writ would speed the appeals just those entities in homeowners “The fact that the court did accept process along. Otherwise, the appeals insurance. our amicus brief we think is certainly process could go on for years and “It’s the commissioner claiming the is not a bad sign,” Young said. draw out a battle that was ignited last authority to mandate underwriting The second district court of appeal year. guidelines through the replacement denies roughly 96 percent of all peti- costs formula,” said Mark Sektnan, tions for writ of mandate, Young said, Legal Battle president of ACIC. “We believe any adding, “We don’t hold out a lot of When CDI and Insurance additional authority has to be granted hope that our petition is going to be Commissioner Dave Jones came up by the Legislature.” granted.” with the regulations regarding how to He added: “If the commissioner continued on page 16
14 | INSURANCE JOURNAL-WEST REGION May 7, 2012 www.insurancejournal.com DECEMBER 2ND, 3:52 P.M. THERE’S NO REPLACEMENT FOR A RELATIONSHIP IN AN INSTANT, JILL SANTOS KNEW AN UNDERWRITER COULD MAKE A DIFFERENCE
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Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. CNA is a registered trademark of CNA Financial Corporation. Copyright © 2012 CNA. All rights reserved.
WEST COVERAGE News & Markets
Replacement, continued from page 14 Long Road insurers, brokers and agents from utiliz- insurer and every broker-agent to estimate However, if the court does end up deny- ing any other replacement cost calculation replacement costs using one and only one ing the mandate, IBA West and the other methodology and asserting that alternative formula.” associations will just take the long road and methodologies would constitute an “untrue, He added it’s his belief that Jones’ legal deal with a normal appeal process, Young deceptive, or misleading” statement in the team “came up with what I think is a pret- said. business of insurance, which is prohibited ty sneaky backdoor attempt to find regula- What’s the hurry? by Insurance Code Section tory authority.” The regulations sought ‘The fact that the 790.03(b), part of the Unfair Pat McConahay, CDI’s deputy press sec- by CDI and California court did accept Insurance Practices Act. retary, defended CDI’s actions and said the Insurance Commissioner our amicus brief we IBA West’s argument new regulations are necessary to protect Dave Jones were not is the regulation imposes homeowners seeking insurance. stayed when an earlier think is certainly is significant burdens on “This regulation is an important consum- court gave the state’s not a bad sign.’ insurance producers, and er protection measure,” McConahay said. insurance regulatory it grants Jones and CDI “When a homeowner comes to an agent to body authority to move forward with the broader powers that could be extended buy a policy and the agent provides an esti- new replacement costs regulations. into other areas of insurance, Young said. mate of how much it will cost to replace The regulations, intended to reduce Young said the standardized set of cri- the home if it is destroyed, the consumer underinsurance in homeowners’ insurance teria “isn’t a bad idea just in terms of the should be given a complete and accurate policies, require all insurance companies to merits of the idea.” IBA West’s issue is that estimate. This regulation achieves that calculate replacement cost estimates using Jones is overstepping his authority, and goal.” a standardized set of more than 20 criteria. it’s the Legislature that makes the laws The regulation places four principal obli- The regulations also require producers to and the administration and CDI’s role is to gations on the insurance industry. provide detailed information disclosing to interpret those laws, Young said. The regulation forbids licensees from customers the amount of the replacement “The commissioner doesn’t have the communicating an estimate of replacement cost estimate, and how it was calculated. legal authority to say ‘Hey, I got a really cost to an applicant or an insured on a The California insurance code doesn’t great idea and I’m going to make every- renewal of a homeowner’s insurance policy necessarily authorize CDI to create such body do the following 25 ideas,’” Young that provides coverage on a replacement mandates. However, CDI lawyers added said. “There’s nothing that says the com- cost basis unless the estimate takes into provisions to the regulations prohibiting missioner can require every homeowners’ account at least 22 factors set forth by CDI. The regulation states that communi- cating a replacement-cost estimate not comporting with the method constitutes a misleading statement and pursuant to California’s insurance code can lead to a rrange of penalties, including fines of up to $10,000 per violation. It creates strict liability for use of third- party sources, meaning licensees are bound by the method even if they rely upon information, data or statistical methods obtained through third-party sources. The regulation requires licensees at least annually to update the sources and meth- ods they use to generate replacement-cost estimates. All associations involved in the suit con- tend the regulations constitute an illegal intrusion into insurance underwriting by CDI, and violate First Amendment rights of insurers by prohibiting non-conforming statements regarding other replacement cost methodologies.
16 | INSURANCE JOURNAL-WEST REGION May 7, 2012 www.insurancejournal.com Avoiding gaps in public entity insurance coverage
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WEST COVERAGE News & Markets Path Set for ACOs in Healthcare Delivery
Speaking at a recent PLUS Medical Frost said there are risks that may Professional Liability Symposium as arise out of the nature of an ACO’s part of a panel on liability exposures structure and its partners, which faced by ACOs, McMahon explained include a variety of providers, vendors that ACOs are both the result of an and other participants. evolution in healthcare delivery models “The ACO liability exposures are in reaction to HMOs and an attempt to similar to historical managed care orga- improve the quality of healthcare while nization exposures in many respects,” keeping costs down. Frost said. However, they differ in With the early HMOs, insurers that there is more freedom of choice would assign “a fixed monthly per for care alternatives — participants patient payment to a provider and can go out of network for care if they that payment was meant to cover all choose — and the financial restraints treatments for that patient,” McMahon on physicians often imposed by tradi- By Stephanie K. Jones said. “In addition, health insurers tional HMOs are absent, so there’s a implemented a lot of cost containment lower risk of litigation over those types ven if the U.S. Supreme Court measures,” such as gatekeeper systems, of exposures. Estrikes down the Obama adminis- under which a patient could only see “Nevertheless there still are financial tration-backed healthcare reform legis- a specialist if their primary care physi- incentives to cut costs and under- lation, accountable care organizations cian provided a referral. utilize, and you can be sure the plain- (ACOs) — models aimed at improving “There were restricted networks, tiffs’ bar will be very focused on those,” the quality of healthcare delivery while there were gag orders forbidding physi- Frost said. decreasing costs — are likely to sur- cians from discussing patients’ alter- ACOs are “assuming accountability vive, say a panel of experts in health- native, albeit more expensive health for quality of care. They also assume care liability issues. care options. … This infuriated the the duty to coordinate that care,” she ACOs are networks of health- American public,” McMahon said. said. Theoretically, the assumption of care providers that band together As a result, lawsuits followed as did those duties should heighten ACO’s to provide for the consistency and multimillion-dollar jury awards. liability risk going forward. coordination of services for patients. ACOs, on the other hand, are “ACOs are the primary provider Developed partly in anticipation of and patient-centric models designed to organization. No matter what they do in response to the Patient Protection implement quality without limiting they’re going to be [responsible] for and Affordable Care Act of 2010, ACOs choice, she said. Common characteris- outcomes and that may lead to negli- are similar in some ways to health tics of successful ACOs include broader gence claims,” Frost said. maintenance organizations (HMOs), access to care with extended hours and Medical treatment is one obvious which were developed in the 1980s and weekend access, case management, exposure that is likely to give rise to fell out of favor mainly due to restric- management of electronic medical claims against ACOs, she said, but tions in care and services available to records, care coordinators and use of there are others. “I think we’re going patients. data analytic systems to track popula- to see more claims on failure to coor- “There are probably as many types tion management. dinate care,” she said. ACOs have an of ACOs as there are car models on the obligation to coordinate care but “that’s market,” said Kristin McMahon, chief Liabilities and Exposures easier said than done. … Where things claims officer for IronHealth. However, While they differ in a number of fall through the cracks for various rea- they mostly fall into two broad cat- ways from HMOs, ACOs may have sons the ACO may be held accountable egories — public and commercial. The many of the same liability issues as for those lapses.” categories are defined by who pays, previous healthcare delivery models, Regardless of the liability exposures whether it’s a governmental entity, according to Ciara Frost, a partner in they may face, ACOs in some form are such as Medicare, or a private insur- the Chicago-based law firm of Kerns likely to remain the future of healthcare ance organization. Frost Pearlman LLC. delivery, the experts say.
18 | INSURANCE JOURNAL-WEST REGION May 7, 2012 www.insurancejournal.com
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