Report: Claims cost of individual health insurance in WA likely to rise 13.7 percent by 2017

A new report by the Society of Actuaries predicts that medical claims costs for individual health insurance plans -- meaning coverage that people have to buy on their own, rather than get through an employer or government program -- will rise 13.7 percent in Washington by 2017. That's substantially less than in many other states.

About 300,000 Washingtonians now buy their own insurance on the individual market. That number's expected to increase sharply next year as people who are now uninsured start buying coverage.

It's too soon at this point to say what the final rates will be. We don't expect to see the first rate proposals for these policies until next month, and premiums include more than just medical claims costs.

There is, however, some good news for many of these folks. The report does not attempt, for example, to factor in the federal subsidies that many people in the individual market will qualify for, starting in January. Under federal health care reform, a family of four earning up to $94,200 could qualify for help paying for their insurance.

Also, under health care reform, the vast majority of policies will cover much more than they do today. It's rare, for example, to find an individual health plan that covers prescription drugs. Many don't cover the birth of a child. Starting in January, most policies will have to cover those things and more.

Lastly, the sad fact is that the individual health insurance market is no stranger to big increases in rates. In 2009 -- well before health care reform -- those policies in Washington rose an average of 16.5 percent. That's in a single year. And the year before that was even worse: an average increase of 18 percent.

Tacoma man arrested for insurance fraud

A 24-year-old man facing multiple charges in an insurance fraud case was arrested this morning by the King County Warrant Team at a residence in Tacoma.

Andre Romeo Zamora Sarmiento was charged last year with second-degree theft, forgery and insurance fraud for allegedly filing altered and fake medical bills after a car accident. He failed to appear for arraignment on Dec. 24, 2012, resulting in the warrant that led to his arrest this morning.

The fraud case involves a November 2011 auto collision in Tacoma. A car turned in front of Zamora's car, cutting him off, and leading to the crash.

Zamora subsequently filed a claim with the other driver's insurer for injuries to his back and $2,542 for vehicle damage to his vehicle. For the medical claims, Zamora filed several bills totalling $14,857.

A subsequent investigation by our anti-fraud Special Investigations Unit revealed that several bills were altered and grossly inflated. A bill for $360, for example, had a "9" added, to make it look like a bill for $9,360. A bill for $33.50 was turned into what looked like a bill for $3,358.80.

All told, Zamora submitted claims for $13,236 more than he actually paid. The insurer paid Zamora $5,497 before discovering that the bills were fraudulent.

Q: "My homeowners insurer sent an inspector to look at my home. Can they do this?"

It is not unusual for home insurers to periodically inspect the homes they insure.

Generally an inspection might be done after years of providing insurance when an insurer may ask if it's still insuring the same risk that it started out with.

The company might ask your agent to do a site inspection, or might hire an independent company to do site inspections and write reports about what they see, such as maintenance, property/landscape care, and any dangerous conditions that might increase the chance of a loss or injury at your home or on your premises.

There are no insurance laws that prohibit site inspections. Of course you’ll want to set up an appointment so you can be there when the site inspection is made. If a site inspection is made on a ‘drive by’ basis, there is a chance that a report may not be accurate, as you won’t be there to answer questions about any issues that could cause an inspector to be concerned, maybe unnecessarily. If you have questions about the process, we recommend that discuss the issue with your agent.

Job opening: Deputy insurance commissioner for legal affairs

Due to a retirement, we're recruiting for one of the top jobs at the Office of the Insurance Commissioner: the deputy commissioner for legal affairs.

The person will be responsible for forming the agency's legal positions related to enforcing compliance with the state insurance code and related federal laws, including matters related to insurers, agents, brokers and unauthorized insurance transactions.

He or she will manage a division of 20 employees and serve as general counsel for the insurance commissioner. The division includes staff attorneys and investigators who support the agency's consumer protection mission.

For more, including detailed responsibilities, requirements, salary and application process, please see the full job listing.

Insurance questions: "What's an `examination under oath,' and do I have to take it?"

Q: "My insurer asked me to attend an `examination under oath.' Can they make me do this?"

A: The company has the right to request that you be examined under oath, but it's your decision whether to actually attend and participate. So you can refuse. But keep reading.

Here's the big caveat: As the insured person, you have a responsibility to cooperate with your insurer during an investigation and to provide support for your claim. If you refuse to attend an examination under oath -- these are often known by the shorthand "EUO" in insurance documents -- your insurer has the right to deny your claim and close their case based on what they will call non-cooperation.

The upshot: We recommend that you attend an examination under oath and that you cooperate with your insurer in support of your claim.

After your insurer has the information it's requested and has completed the exam, then it's their responsibility to provide you with a timely coverage decision. If they deny your claim, they need to clearly explain to you why they made that decision.

If you live in Washington state and have insurance questions or want to file a insurance complaint, you can reach us by e-mail or call us at 1-800-562-6900. You can also file a complaint 24/7 through our new online complaint form.

If you live in a different state, here's how to reach your state's insurance regulator.

"An accident drove up my insurance rates, but I wasn't at fault. What's up?"

Some auto insurers base their rates only on at-fault accidents, but others take into consideration all claim activity, whether you were the one at fault or not.

Insurers operate on the statistical principle  that people with current claim activity represent a higher future potential risk than those who have no claims.

Here's the good news: insurers compete against each other, and in Washington we have a particularly vibrant auto insurance market. And rates can vary considerably from company to company, even among similar policies. So -- as we say often -- it really can pay to shop around for alternatives.

"I got the check for my car repair, but it doesn't include all the damage."

Q: "The insurance claims adjuster sent me a check for my car repair, but what if there are added repairs that still need to be made?"

If there is other accident-related damage that was missed in the initial estimate, then have the repair shop call the claims adjuster to verify the damage and authorize repair.

Here's the key part, though: That call has to happen before repairs are made, since the adjuster must verify that the damage is related to the covered accident.

If there is no verification and repairs are made, you may be responsible for paying the added costs.