Caffery, Oubre, Campbell & Garrison, L.L.P.

The Federal Jones Act: Its Purpose And Scope

2023-10-05T11:33:13Z

It makes eminent sense that personal injury claims and related insurance issues in Louisiana often address water-linked matters. After all, “The state of Louisiana boasts hundreds of miles of gulf coastline, several major ports along the Mississippi and countless miles of inland navigable waters.” That quote comes via our website at the proven and long-established Lafayette insurance defense law firm of Caffery, Oubre, Campbell & Garrison. Our deep legal team provides staunch and tailored advocacy promoting the rights of business principals and insurers across Louisiana, with our representation often focusing on waterways and linked maritime considerations. Notably, we defend our valued and diverse clients in injury claims involving Louisiana workers’ compensation laws. When those do not apply (which is often the case in coverage claims involving alleged offshore injuries), our attorneys work within the confines of the federal Jones Act. That legislation has been firmly established across much of American history. Indeed, the Jones Act was enacted nearly a century ago, back in 1920. An in-depth online overview spotlighting the seminal law notes its important function “to protect mariners injured at sea, since they are not qualified for workers’ compensation under maritime law.” An initial and key point regarding legal representation of a commercial entity and/or an insurance provider in a matter alleging a mariner’s personal injury incurred at sea is this: It is vitally important that a retained law firm has demonstrated acumen in what is a specialized and technical area of law. We welcome contacts to our firm concerning any aspect of maritime insurance defense, as well as the opportunity to diligently represent valued clients in this singular area of law.

The Staggering Scale Of Auto Insurance Fraud

2023-10-05T11:34:12Z

They don’t always get the big headlines, but auto insurance fraud cases happen frequently. In Louisiana, the State Police Insurance Fraud/Auto Theft Unit announces arrests and investigations regularly. Cases may involve staged crashes, falsely reported injuries or other schemes meant to bilk insurance companies out of money.

Understanding just how big of a problem auto insurance fraud is can be difficult. However, some figures offer an idea. And the numbers are staggering.

What the numbers suggest

Auto insurance fraud is believed to be widespread and one of the most prevalent forms of insurance fraud out there. According to the Coalition Against Insurance Fraud, insurers found indicators of potential fraud in 7.4% of auto claims within the first 125 days of filing. In addition, about one in five bodily-injury and personal injury protection claims closed with payment showed some evidence of fraud or buildup.

In dollars, auto claim fraud and buildup tacked on an extra $5.6 billion-$7.7 billion in payments to auto-injury claims paid in the United States in one year alone, accounting for 13-17% of total payments. And none of this considers the potentially billions lost in premium leakage.

A Fortune 500 company

All together, these behaviors have a huge impact on the insurance industry. The National Insurance Crime Bureau puts it succinctly: Insurance fraud generates so much money, if it were a legitimate business it would qualify as a Fortune 500 company.

Auto insurance fraud can involve complex, organized schemes, with many people playing a part. This can make some cases hard to untangle. While suspicious loss indicators and improving technology may provide some solutions, these can’t catch everything.

Clearly there is a lot of money at stake. If you suspect a suspicious claim has been filed, you might benefit by having an attorney help review the case, or even assist as local co-counsel in these questionable claims.

What Are The Widespread Ripple Effects Of Insurance Fraud?

2023-10-05T11:34:43Z

It is likely that many people in Louisiana and nationally don’t get especially heated when they hear a story chronicling an egregious attempt to defraud one or more insurance companies. Indeed, the bad-faith effort of a scammer making bogus claims to garner unlawful profits is concerning, but its effects are relatively confined and do not generate broad-based public harm. Right? Well, actually wrong, and in a deeply emphatic way. In truth, and as noted in a recent article on the topic, insurance fraud spawns a double whammy of detriment. First, it increases insurance costs for immediately involved parties. And, second, it throws a punch at the general public as well. Insurance “is basically pooling risk,” notes one industry principal. Claimants who receive payouts draw from the well, which must be replenished. Other policyholders refill it, typically through increased premiums. Those can be more than marginal when good-faith payers are on the hook for insurers’ payments to fraud artists. How prevalent is insurance fraud in the United States? Reportedly, it is uncomfortably common. Insurance regulators state that it lags only illegal drug sales as the most profitable crime in America. It is estimated that attempts to fleece insurers conceivably end up costing the public as much as $120 billion annually. That is a notably large chunk of change, to be sure. Extrapolated, it comes out to a nearly $330 million scamming every day of the year. Insurance fraud is not a victimless crime. Indeed, it is a widespread scourge that routinely robs the public at a stunningly high level.

Spotlight On Out-Of-Network Providers In Emergency Situations

2023-10-05T11:35:12Z

A story like the following will never garner positive publicity points for an insurance company. In fact, it will assuredly yield an immediately sharp public response, even without regard for underlying details.

A recent Consumer Reports article highlights the tale of a young girl who was injured while on a skiing vacation. Local hospital authorities made the decision to airlift her to another facility for treatment. The bill for that service was $65,000.

The family’s insurer balked at paying that stunning amount, stating that the air ambulance company was an out-of-network provider and that permission to use its services wasn’t preauthorized. The hospital countered that preauthorization was not required, given the extensive nature of the girl’s injuries.

As noted above, it’s not hard to gauge where public sentiment will reside in such a story. Insurers are frequently painted with a broad brush of condemnation in narratives featuring their questioning of medical charges.

Such questioning often targets truly unexpected medical charges, though, as well as legitimate inquiries into highly ratcheted-up costs charged by some non-network providers. And it is not often that an insurance company becomes embroiled in a story where a failure to pay is linked with a clearly objectifiable emergency. The above article notes, for example, that insurers’ objections are far more often directed to instances of care that is delivered in an arguably non-emergency situation.

Insurance companies logically seek cost controls concerning coverage, just as their policyholders do. Indeed, insurers and insureds have a shared – not a contrastive – interest in striving to keep medical bills logically tied to services rendered. Rules and processes concerning preauthorization, standards for emergency care and network designations all speak directly to the need for mutually beneficial cost containment.

Reportedly, the topic of surprise medical bills is currently a top-tier agenda item for Capitol Hill legislators. Insurers welcome the focus and look forward to lawmaking guidance on the subject matter.

Louisiana Regulators’ Response To Broad-Based Medicaid Fraud

2023-10-05T11:35:40Z

It’s a $100 million annual fleecing of Louisiana taxpayers and insurers paying out Medicaid claims. And it reportedly involves legions of insureds who come nowhere close to actually satisfying the threshold income requirements for garnering eligibility. We reported on the “stunning” results of a Medicaid-focused investigative probe in a recent blog post. We noted in our June 4 entry that “alarmingly high numbers of well-heeled state residents are wrongly enrolling in Medicaid expansion that has been occurring over the past several years.” Louisiana lawmakers – and, of course, defrauded insurers – want to see the ruse stopped. One researcher and public policy expert terms the reality of mass outlays being expended on persons making Medicaid claims who don’t pass eligibility muster a “moral hazard.” What especially galls many commentators on the matter is the fact that high numbers of people with notably high incomes who were granted Medicaid eligibility already had health policies. Their mass applications have overwhelmed processors and made things notably difficult for lower-income individuals and families that truly do qualify for Medicaid. “We are spending taxpayer dollars to subsidize people who already had health insurance,” notes the above-cited public policy principal. Clarity and needed change now seem forthcoming in the wake of state congressional action. Louisiana House Bill 72 recently passed through chambers and is now being considered in the senate. HB 72 seeks to give regulators expanded auditing power over the Medicaid program. If enacted, a tandem bill in the senate (SB 179) would provide for close scrutiny of current Medicaid recipients with over-the-threshold incomes. The widespread program irregularities are widely harmful for a diverse demographic across Louisiana. Fraud and abuse in the state’s Medicaid program will hopefully be fully identified and strongly responded to without delay.

Spotlight: Cyber Risks, Management In Maritime Industry

2023-10-05T11:36:08Z

As far as distinct industries are concerned, the maritime/admiralty realm is about as singular as it gets. Its broad and diverse range of actors includes petrochemical companies, commercial fishing businesses, recreational outfits, goods suppliers/haulers and legions of other entities.

Moreover, those participants navigate on both domestic and international waterways. In doing so, they are subject to legions of national and international laws, as well as guidelines and suggestions authored by various agencies and global bodies.

In short, the maritime industry is starkly differentiated and notably complex. One recent in-depth media spotlight on the realm simply calls it “unique.”

That article underscores a specific challenge for the maritime realm, namely, the industry’s growing threat from cyber risks and its need to smartly anticipate and respond to them.

Cyber threats are a constant and ever-growing phenomenon in today’s world, of course, and the maritime industry is not immune from the risks. Indeed, it is a logical target for would-be disrupters having various motives, and its vulnerabilities are multiple and varied.

The writer of the above piece – a longtime industry insider and commentator – notes a handful of “the many vulnerable systems within marine operations.” They range from bridge systems, power controls and communication networks to passenger management, cargo handling and navigation processes. Virtually everything involving technology, computers and the Internet is a concern.

Those with the duty to prepare against cyber risks/incidents and purposefully respond when they occur obviously have a heavy plate of responsibilities. The aforementioned article stresses that a key part of any cyber defense plan for decision makers is “properly managing your risk with adequate insurance coverage.”

Questions or concerns regarding cyber-linked matters in the maritime industry can be addressed to proven Louisiana insurance defense attorneys commanding experience in that complex realm.

How Far Do Federal Sex Discrimination Protections Extend?

2023-10-05T11:36:47Z

The enactment of the federal Civil Rights Act of 1964 ushered in sweeping changes regarding work-related protections for American employees. Title VII of that law codified a bullet list of categories to be safeguarded against discriminatory workplace practices and behaviors.

One of those categories is sex. Courts across the country have reiterated in legions of cases since 1964 that employers may not discriminate against workers on the basis of sex.

Although that seems clear enough facially, the parameters of that protection have never been as broad as many people think. In fact, federal law as it currently stands does not bar employers from discriminating against lesbian, gay, bisexual and transgender workers.

Understandably, a wide swath of the American public wants to see a legal change that codifies protections for LGBT employees under Title VII. The U.S. Supreme Court is slated to hear a case later this year that will centrally address the issue.

In the interim, proposed federal law entitled the Equality Act is gaining considerable traction nationally. As one media report spotlighting the would-be law notes, it “would expressly include sexual orientation and gender identity” under the “sex” umbrella referenced in Title VII and other federal anti-discrimination laws.

The above article notes that a majority of states -- including Louisiana – have not passed laws to protect workers against both gender identity and sexual orientation discrimination.

Many commentators on the subject matter suggest that employers in those states might reasonably want to act now to stay a step ahead of legal changes that are likely coming, and relatively soon.

The professional human resources group SHRM is one proponent of proactivity. It states that, “As a best practice, employee handbooks and policies should include prohibitions against discrimination on the basis of sexual orientation, gender identity, gender expression and transgender status.”

Many employers understandably have questions or concerns about local, state and federal laws concerning workplace discrimination (and potential blowback from employees). They can contact a proven employment practices liability defense team for candid guidance and, when necessary, diligent legal representation.

Workers’ Comp For Issues Related To Opioid Addiction

2023-10-05T11:37:16Z

A recent influx in cases involving the use of opioid medication for catastrophic injuries and surgery, related to workers compensation claims, resulting in major and expensive dental procedures has caused both workers compensation adjusters and stakeholders to stand up and take notice. Opioids are one of 1,800 types of medications that can lead to dry mouth which can be linked to dental damage and costly treatments.

The problem with growing dental claims

It can take aWowhile for bills related to workers compensation to come through, sometimes even taking up to a year or two after the treatment until they are fully processed. Because of this, the problem has likely worsened, and treatments continue to pile up as the patient may be unaware that the problem stems from their use of opioid medication or may not understand the proper hygiene steps they need to take to counteract it.

Opioid use can be linked to dental problems for two primary reasons. The first is that it limits the buildup of saliva in your mouth. This can cause the food debris to remain on the teeth longer, leading to tooth decay and gum issues. Another common problem is that when taking opioid medication, the patient may feel less pain and may not realize they have an affected tooth until the decay has become severe.

How to prevent major dental issues with opioid use?

While it may not seem to be a significant concern when first addressing the issues of an injured worker, the earlier that they are treated for dental problems caused by dental use the better. This can include educating workers on the dental issues that can occur and encouraging them to seek out dental treatment early in the claims process.

The opioid crisis causes more than dental concerns

Unfortunately, dental problems are only a small part of the problem that can occur by regular use of opioids. Workplace injuries can often result in chronic or long-term pain, and it is these workers that are at a much higher risk for addiction or dependency. Even short-term use for injuries can lead to dependency issues and a host of other problems. Other problems that long-term opioid use for workers compensation claims can lead to include:

A delay in the injured worker's return to work - Injured workers who are receiving higher doses of opioids will stay off work three times longer, on average, than those with similar injuries who have been prescribed lower doses.
Safety issues with the recovering employee or their co-workers - When taking opioids, you can be less alert and have a slower reaction time. Because of this, they not only put themselves at risk when returning to work, but also their co-workers as well.
Lower productivity and more missed days - When opioid use turns into an addiction, workers will lose more work days and will often be less productive in their jobs.
Higher claim costs - The claim costs for those prescribed high doses of opioids will be much higher on average than claims of those with similar injuries who are not taking them. Claims cost will rise due to longer recovery times, drug addiction treatment, more time off work, and higher prescription costs.

Is there a connection between worker's compensation claims and a higher risk of opioid addiction?

Prescription opioids have long been a go-to for injuries, and most worker's compensation claims are related to these types of injuries. But there are other factors that can lead to a connection between worker's compensation claims and opioid dependency. The first being the nature of the doctor/patent relationship. Physicians tending to patients in a workers' compensation situation will spend significantly less time than the typical doctor/patient relationship. With the connection between worker's compensation claims and opioid addiction becoming more apparent, it is more important for providers and stakeholders to put systems in place to help battle the opioid crisis in the country.

How Has Medicaid Expansion Defrauded Louisiana Insurers, Taxpayers?

2023-10-05T11:37:49Z

What is one material benefit of commanding a higher salary than Louisiana Gov. John Bel Edwards?

Notably, it is still being able to establish eligibility for enrollment in Medicaid.

That might sound flatly far-fetched to readers of our insurance defense blog across Louisiana. After all, Medicaid is a national health care program that is ostensibly limited to only uninsured and low-income individuals across the country.

Nonetheless, the income restrictions applicable to Medicaid didn’t stop at least one Louisiana individual with an income surpassing the state’s chief executive from garnering program eligibility. In fact, the nonprofit Pelican Institute for Public Policy reveals that alarmingly high numbers of well-heeled state residents are wrongly enrolling in Medicaid expansion that has been occurring over the past several years.

Here’s one stunning takeaway from Pelican’s recent investigative probe: Evidence points to at least 1,600 Louisiana residents enrolled in Medicaid who make more than $100,000 annually. Most of those individuals disenrolled from private health care plans in order to take advantage of Medicaid’s comparatively lower costs.

That reality signals fraud to state regulators, with a special spotlight focusing on Louisiana’s administration of the program. It is estimated that ineligible enrollees are costing the state approximately $100 million annually. Overall, Louisiana reportedly has about 480,000 Medicaid expansion enrollees, which costs the program $2.5 billion each year.

Taxpayers are on the hook for a portion of that amount. And, of course, Medicaid insurance companies regularly pay out huge amounts of money. For obvious reasons, insurers want to see the full extent of program fraud fully spotlighted, with irregularities eliminated.

What Are Some Key Indicators Of Workers’ Compensation Fraud?

2023-10-05T11:38:42Z

“Blind faith can end up costing you.” Although that warning is explicitly directed toward business employers in Louisiana and nationally, a recent in-depth media article on workers’ compensation fraud additionally underscores its relevance for the general public. That piece stresses the broad-based downside of workers’ comp-linked wrongdoing for insurers, consumers and taxpayers as well. How big is the problem? Reportedly, and as we note in our May 23 blog post at the proven insurance defense law firm of Caffery, Oubre, Campbell & Garrison in Lafayette, outsized indeed. One estimate pegs the annual economic damage of workers’ comp fraud in the United States at about $7 billion. Thus, the admonition – especially for employers – to routinely be on the close lookout for ruses aimed at bilking the system and unlawfully collecting accident/injury benefits linked with bogus claims. The above-cited article points to several “red flags” that might reasonably trigger an employer’s suspicion that fraudulent behavior is being committed. Here are some representative indicators:

No third party can verify that a workplace accident or injury actually occurred
The claimant has a personnel file that points to a pattern of workers’ comp claims
There is an inexplicable lag between the time an injury allegedly occurred and its formal reporting
Claimant balks at medical treatment and diagnostic testing

Workers’ compensation fraud comprises multiple variants. Obviously, a claim might be altogether false; the alleged accident or injury simply never happened. It is sometimes the case, too, that a claimant materially exaggerates an incident. And while some workers do indeed suffer injuries, those might have occurred at home or some other venue outside the workplace. Workers’ compensation fraud is broadly injurious to the public. An employer suspecting an attempt to cheat the system should immediately contact insurance company officials, who can benefit in turn from securing the close and studied input of experienced insurance defense attorneys.