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Researchers: LTC Insurance Keeps Some in Homes

If the Supreme Court had accepted the arguments of the plan participants, the Labor Department and the 2nd Circuit, that would have posed “a substantial threat to employer plan sponsors by subjecting them to class-wide relief for a miscommunication without requiring any showing of harm,” Myron Rumeld, a employee benefits partner in the New York office of Proskauer Rose L.L.P., says in a comment on the case.

If the participants had prevailed, a court could have enforced the terms of an SPD as understood by the participants, rather than terms of the plan itself, Rumeld says.

The Supreme Court now has made it clear that plan participants must show that an employer committed fraud in an SPD, or that an error caused harm, before they can ask a court to impose forms of equitable relief such as equitable estoppel, plan reformation, or surcharge, Rumeld says.

“The Supreme Court rejected the notion that there is a ‘one size fits all’ approach to claims based on faulty communications, such that all participants automatically recover additional benefits that were never intended under the terms of the plan,” Rumeld says. “The court correctly concluded that the SPD is merely meant to be a summary of the plan, and thus the mistaken terms of the SPD should not be enforced as a contractual matter.”


The Role of Broker in
Post-Health Reform World

The idea that everyone should be forced into having healthcare coverage is best compared to that of what happened with auto insurance when states established mandates. Each state figured out how to solve their problem on an individual state basis and it worked. Some chose no-fault like North Carolina and others like California chose liability or comprehensive coverage as a minimum coverage level. But each state came up with a solution that was affordable and yet reasonably priced to meet the budget and demand of consumers in that area of the U.S. The only problem with this comparison is that auto insurance minimums are typically sold with a $500.00 deductible, and no or very little first dollar coverage and a 300k or 500k per incident maximum compared to that of the essential minimum U.S. healthcare with typical PPO plans having a first dollar coverage and unlimited annual and lifetime maximum coverage. The next problem with the exchange is that of a pooled concept. If you study pools and MEWA’s they all have had a similar problem, adverse selection and most consumers keep coverage for a short term basis and over the long term, the pool becomes so high risk that losses must be subsidized. The state pools could possibly be a viable home for the uninsured and the un-insurable. So while the concept of a “pool” of employees and “bigger is better” and sounds good it has not proven to work and has resulted in increases that have proven to outpace the small group and individual market place. Leasing companies, PEO’s, and States pools have all tried and have not been successful on managing this risk. So my suggestion is to subsidize the un-insurable and make a risk pool per carrier that is government subsidized and leaves the private sector alone and lets pricesbe set by demand not artificially by a government subsidy and a tax penalty if you chose not to participate. While healthcare in the U.S. out-trends inflation it is by far the greatest and most advanced in the world. Doctors come here from other country’s for no other reason than opportunity and income potential. I believe in making all things affordable but with the heavy regulations and the trend of unhealthy people in our country there is no wonder the price of coverage continues to increase. I am a business owner, advisor and insurance producer and I do not like the idea that insurance carriers can deny coverage but the exchange, just as the state pool, will attract risk and as high if not higher increases than we have had historically. So why not just focus on the problem instead of the issue. The focus should be on getting the uninsured and un-insurable insured. And the ones that wish to not protect themselves from a catastrophic event just like a home owner with no home owners insurance must take that risk upon themselves and pay or accept the loss.

Matt Williams

I have no doubt that regulators will say that brokers will have some sort of place in helping people purchase insurance through Exchanges. What I also have not doubt of is that we won’t be getting paid a fair wage for our work, so the number of brokers out there will be very small once these Exchanges do hit. I already get phone calls from people who went online to get the insurance and don’t understand it, so they want me to take my time and explain it to them. I don’t make one penny from doing that and it takes away from the time I could spend time working on things that do make money, but I don’t refuse to help. It’s my job to help. I just won’t have a job much longer since I can’t afford to work for free.


It’s amazing to me that MLR has “forced” carriers into shifting to a “per head” commission structure while I have not heard a word about the fat cats in the ivory tower taking substantial pay cuts. I ask my clients all the time, “Are you prepared to have to start dealing with your insurance company directly?” So far not one of them has told me yes. In fact, several of my clients have asked me how much I will be charging them to continue as their broker. The funny thing is that the companies leading the charge, Aetna, Blue Cross, etc. are the companies that, as a consumer, you would want to deal with directly the least. The “Motor Vehicle Department-like” mentality of these carriers will only make things worse then they already are. We are completely doomed.



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