Enrollment hits nearly 6.5 Million in Federal Health Exchange

Nearly 6.5 million individuals signed up for health insurance plans through the federal exchange during the first six weeks of the 2015 open enrollment, the U.S. Department of Health and Human Services reported Tuesday.

2014 and Beyond!

My apologies to all my followers for the radio silence in the last few months. It has been a tumultuous year.

After recovering from a heart attack in 2013, I had intestinal surgery in June of this year as a result of complications and was in hospital for 9 days.

I recently got a divorce but fortunately got to keep my house, my kids and win support.

I am also dealing with the debilitating sickness of both parents.

But I stay strong and look to my faith........

Seasons Greetings and Happy New Year to All!

World Cup Brazil 2014 - A Primer!

Every four years the world go's ga-ga for the most famous sporting tournament in the world - the World Cup.

The tournament is held only once every four years which makes it even more exciting - with the title of the world's best up for grabs. Teams must go through almost 2 years of qualification just to have the right to appear.

The host nation (this time it is Brazil) is decided/awarded 8 years before the tournament begins and is based heavily on politics and of course money. Brazil has been beset by monetary and human rights problems surrounding the construction of new stadiums and although I am sure the tournament will go off without a hitch, there will be a lot of undertones which could become a distraction. In short, when a nation can barely afford to feed its people why should they spend billions on sporting arenas that may be used only sporadically after the tournament is finished.

Interestingly, although Brazil as the home nation is the favorite to win, only 4 host nations have triumphed in the last 48 years (12 tournaments).

Here, thus, are my predictions as to the outcome of the 2014 World Cup Finals - based on the teams that will come out of the groups and on to the finals.

Group A -Brazil and Croatia to move forward. The sheer beauty of Dalmatian women will mesmerize the Brazilians but not enough to thwart their advance to the Semi-finals.

Group B - Holders Spain and beaten finalists from 2010, Netherlands, should advance, but Chile will pose a threat. Although somewhat ageing, look for Spain to advance to the Semi-Finals.

Group C - Look for Colombia and Ivory Coast to move forward - although Japanese work ethic will put them in a position to surprise.

Group D - One of the groups of death - England, Italy, Uruguay and Costa Rica. If Luis Suarez doesnt bite someone, Uruguay can be a threat. Never count out Italy. England are building for the future.

Group E - France and Ecuador - The French owe their nation from last World Cup; The omission of Samir Nasri was strange.

Group F - Argentina and Nigeria.

Group G - THE group of death.......Germany is a no brainer, US - fugget about it. Ghana and Portugal to vie for second place.

Group H - Belgium is the sexy pick......Russia will join them in the second round.

Semi-finals:

Brazil, Spain, Argentina and Belgium.

Final:

Argentina beats Brazil.

Pennsylvania Superior Court Finds Coverage Under CGL Policy For Product Defect Claims.

Policyholders seeking defense costs for products liability claims received welcome support from a Pennsylvania appellate court which rejected an excessively restrictive view of the scope of coverage offered under commercial general liability (CGL) policies. The court in Indalex, Inc. v. National Union Fire Insurance Co. of Pittsburgh, Pa., reversed, or at least slowed, what appeared to be a trend in that state toward expanding the notion that product defect claims amounted to complaints of "faulty workmanship" that lacked the "fortuity" contemplated under an occurrence-based CGL policy. In deciding that the manufacturing and design defect claims at issue in Indalex-constituted an "occurrence" and thus were covered, the opinion reaffirms one of the basic purposes of purchasing a standard CGL policy, namely, to protect against third-party personal injury and property damage claims purportedly arising from the manufacturer's product. It also underscores the breadth of an insurer's duty to defend and instructs on the proper analysis a court should apply in determining whether that duty exists. A court must consider all claims asserted against the policyholder and may not focus on what it deems to be the "gist" of the action, as the duty to defend is triggered so long as one claim falls within the scope of coverage.

The coverage dispute in Indalex arose out of products liability litigation against door and window manufacturer Indalex, in which the plaintiffs claimed they suffered mold related health issues and property damage from water leaking through Indalex's purportedly defective doors and windows. When Indalex's primary policies were exhausted, National Union Fire Insurance Co. of Pittsburgh, Pa., which issued a commercial umbrella policy to Indalex, refused to defend, claiming that there had not been an "occurrence" which triggered coverage. The lower court agreed, relying upon a line of Pennsylvania cases holding that claims brought for faulty workmanship "do not present the degree of fortuity contemplated" by the definition of an "occurrence" in a general liability policy.

On appeal, the Superior Court of Pennsylvania reversed, holding that the underlying complaint did not limit its claims based solely on faulty workmanship but included claims alleging damage to property other than the insured's own product, and thus covered under the CGL policy. The court also noted that the policy's definition of "occurrence" contained subjective language, as "occurrence" was defined as "including continuous or repeated exposure to conditions which results in bodily injury or property damage, neither expected nor intended from the standpoint of the insured." Arguably, Indalex did not expect the mold related health problems purportedly suffered by its customers.

In reaching its conclusion, the appellate court distinguished the line of cases relied upon by the trial court. Two of those cases, according to the Superior Court, involved contract and warranty claims against the insured for property damage to the insured's product due to faulty workmanship. By contrast, the claims asserted against Indalex were not confined to physical damage to the insured's own product but involved "off the shelf" products that had failed, causing personal injuries and property damage to someone other than the policyholder.

The Indalex court also concluded that the trial court did not apply the proper analysis in deciding whether National Union had a duty to defend. By applying the "gist of the action" doctrine, under which a court may disregard asserted tort claims if it determines that the gist of the complaint is based on a contractual dispute, the trial court ignored legally viable tort claims pled against Indalex. Noting that the Pennsylvania Supreme Court had never applied the "gist of the action" doctrine in the insurance context, the-Indalexcourt concluded that its application in determining an insurer's duty to defend was inappropriate.An insurer has a duty to defend the entire suit when any claim asserted against the policyholder is potentially covered and thus a court must consider all claims in determining whether that duty exists. The gist of the action doctrine, the appellate court concluded, is therefore "inconsistent with the duty to defend."

Indalex should, correctly, put the brakes on a trend in Pennsylvania toward limiting the scope of commercial liability insurance in products defect cases. As a majority of courts have held, third-party personal injury and property damage purportedly caused by design or manufacturing defects in the insured's product constitute an "occurrence" and thus may be covered under a CGL policy. Those claims should not be shoehorned into the faulty workmanship exclusion. The opinion also serves as a reminder that, when analyzing an insurer's duty to defend, a court may not disregard tort-based claims in suits against the insured. Because the duty is triggered if there is even a possibility of coverage, as determined by the language of the complaint against the policyholder, a careful analysis of all of the underlying claims is required.

New York's Worst Law - The Scaffold Law!

The 129 year old Scaffold Law, unique to New York, has made the state the most expensive state in which to build a project - from a house, to a school or hospital, to the World Trade Center or a new Tappen Zee Bridge.

This law makes the contractor AND the property owner absolutely liable for any gravity related injury on a construction job site, regardless of fault.

In the case of large public projects, the added insurance and settlement costs can run into hundreds of millions of dollars. Thus hundreds of projects don't get built each year which costs the state tens of thousands of construction jobs with good benefits.

Even if the construction company has provided all of the safety training and equipment that the law requires and the injury was caused by employee negligence, the contractor and property owner still bear 100 percent of the cost.

The law as written treats good, responsible contractors and owners - who provide safety equipment and training - the same as it does the bad actors who don't.

Finally, many insurance companies are no longer willing to write policies for construction projects in New York

Foreclosure Relief for Homeowners!

Effective January 10th, the Federal Government implemented new rules to ensure that borrower's don't get stuck with mortgages they can't afford - and the nation doesn't fall into another housing crisis.

The new rules create a special category of qualified loans that have even higher standards. With these types of mortgages, a borrower's debt to income ratio has to be less then 43% and the loan can't have risky features like negative amortization and interest-only payments.

Points and fees will be limited - no more then 3% for a loan of more than $100,000.

There are also welcome changes for distressed homeowners.

Mortgage servicers will now have to call you by the time you are 36 days late on your payments and with limited exceptions, servicers cannot initiate a foreclosure until you are more then 120 days delinquent.

Finally, if you're having trouble making payments, your loan servicer will have to work harder to help find a solution.

What if Santa had to buy Insurance?

Not only that, but what kind of insurance would he need, and for that matter would he even qualify?

Right off the bat, Santa’s house and workshop are located in a protection class 10. In general terms, this means there would be no responding fire department in the event of a fire at his dwelling or workshop.

While Santa would need property-insurance protection, he would find himself limited to high-risk property markets that may struggle to establish an accurate value for his home and business property. He also doesn’t need a personal-auto policy as his only vehicle – his sleigh – is for business use (this is, however, a commercial-auto exposure, which I will address later).

What’s left? Maybe life insurance? I’m pretty sure Santa would have a tough time finding coverage based simply on his age and, not to be rude, he would also be a few pounds over the maximum acceptable weight.

Sounds like he’s going to face some barriers when it comes to personal insurance, but maybe we could help him out with his business insurance. We already know the property policy is going to be a tough one to write for the workshop, but what about general liability? Santa is a toy manufacturer and that’s not an easy class of business to write. His products are used by children, distributed worldwide, and failure of or injuries from his product could be subject to multiple jurisdictional lawsuits. 

I’m afraid that, with the type of product he is producing and his worldwide distribution, this would also be a tough policy for him to procure.

Santa may also have a need for errors and omissions or professional-liability insurance. He claims he knows when you are sleeping and knows when you’re awake. He also claims to know if you’ve been bad or good…so be good for goodness sake! 

What would happen if Santa arrived when you were awake or, even worse, you had been good but yet your gift was delivered in error to another party currently on the naughty list? Without proper professional-liability protection and the Ebenezer Scrooge of attorneys, Santa might find himself in some serious litigation without the proper cost of defense being provided. 

Now you may be thinking, “Who would take Santa to court?”

But may I remind you that this would not be his first time! You may recall he appeared in court to face some identity-theft claims that arose while he was working for a department store on 34^th street. The charges were later dismissed, but there were still defense costs associated.

Now let’s explore that business-auto policy. We have some big problems here! First, Santa uses a custom vehicle mainly for delivery purposes and while it’s only used one day of the year, his delivery radius is huge, he travels many miles, and let’s not forget about those icy conditions. 

Santa also has some potential loss and MVR issues. The claimant’s grandson insists that Santa was involved in a hit and run when his grandma got run over by a reindeer while returning home on Christmas Eve. Santa also had a theft claim when it was reported the Grinch attempted to steal Christmas. Then there’s the problem of trying to put a value on his vehicle. All in all, I think a commercial-auto policy is out of the question.

Now what he might want to consider is an aviation policy, although he’ll need to go to a specialty market for that. Maybe we could do something to help with his eight reindeer, although I doubt there are any livestock mortality tables for flying reindeer. Perhaps we could try to offer him some kind of equipment breakdown coverage? No, that won’t work – all manufacturing is done by hand not by machine.

This leads me to another tough policy – workers’ compensation.  Oh my, where do I begin? Santa’s workforce uses older manual tools and would be subject to repetitive motion and other injuries. We also have a potential issue as his entire workforce has a height challenge. Hopefully he is in compliance for that but I’m not familiar with what OSHA or ADA requirements exist in the North Pole. 

Santa may need to consider an employer’s protection liability policy. Santa has an aging workforce and, let’s face it, with a diet of mostly candy they could have a lot of potential health issues, so I’m pretty sure workers' comp and group health are going to be tough to get. 

I guess Santa could look to a disability policy for himself, but treading across icy roof tops and sliding down into confined spaces, I’m sure, will make even the most warm-hearted underwriter still issue a decline notice.

Well one thing is clear: being Santa’s insurance agent or company would be a difficult task. I guess Christmas is not meant to be underwritten but to be enjoyed in the company of our loved ones. So parents, assure your kids that Santa will be passing through yet another successful year without incident, albeit self-insured, and, in his words, a Merry Christmas to all and to all a good night.