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Life Insurance Claims Bad Faith & Affordable Care Act Expert Witness

Provides Opinion & Testimony In:

Life Insurance claim denials of any kind, Life Insurance Contract Policy disputes of any kind, Bad Faith issues Life Insurance Policies, Negligence issues Life Insurance Policies, Breach of Contract issues Life Insurance Policies, Agent, Broker Producer Fiduciary Responsibilities regarding Life Insurance Policies, Unfair Claim Settlement Practices, Unfair Trade Practices, Claim Procedure issues Life Insurance Policies, Guardianship Conservator issues Life insurance Policies, Estate Trust issues Life Insurance Policies, Beneficiary disputes Beneficiary issues Life Insurance Policies, Waiver of Premium issues Life Insurance, Viatical Settlement issues Life Insurance, Policy Lapse Policy Cancellation issues involving Life Insurance, Coverage disputes involving Life Insurance, Investor Stranger Third Party Owned Life Insurance transactions , Individual Long Term Disability Claim Denials , Individual Disability Policy disputes, Cancer Critical Illness Policy disputes Claim Denials, , Proper Sales Practices, Underwriting Guidelines, Sales Practice Administrative matters, Life Claims Procedure, Claims of any type, Life Underwriting Process, Life Claims, Claim Decision process, Accidental Death Claims, Investor Owned Life, Insurance matters, Accidental Death benefits, Life Policy Rescissions, Policyholder Rights, Health Policy Rescissions, Policy owner Rights Responsibilities, Employer Sponsored benefits, Stranger owned Life Insurance, Investor Owned Life Insurance, Billing Coding, Medical Billing Review, Medicare, Medicaid, Accident Health Policy claims issues, Obama Care, ACA Affordable Care Act Calculation of Subsidies, Undocumented workers, Temporary workers, illegal alien insurance exchanges

 

 

Expert No. 3560
 

Professional Profile     

Insurance Administrative and Adjudicative Hands-on Experience and Subject Matter Knowledge and Expertise Below:

SME (Subject Matter Expert) and Policy and Claim Administrative & Adjudicative Expert on and within the following Insurance Areas, Matters, Issues, Policies, Claims Products and Coverages:

  • Group Life Insurance and Group Health Insurance Claim and Policy matters, Individual Life Insurance and Individual Accident and Health Insurance Claim and Policy matters, Life Insurance Policy Reinstatement, Lapse, and Grace Period Expert, Regulatory & Compliance issues, Unfair Claim Settlement Practices, Unfair Trade Practices by Insurance Companies, Bad Faith expert, Adverse Claimant proper procedures and claim handling, Proper Claim Handling procedures, Stranger Owned Life Insurance transactions, Investor/Third Party Life Insurance transactions and how they are administered, Business Use of Life Insurance Expert, New Healthcare Reform rules and Regulations expert, Patient Protection and Affordable Care Act provisions, procedures and administrative expert, MEWA Plan Expert, Medical Expense Policy and Claim handling expert, Supplemental Group Medical Benefits expert, Group Medical benefits expert, Group and Individual Health Insurance Claim and Policy Administration expert, Health and Medical coverage expert in rules, regulations, procedures, and claim handling procedures in all types of Life Insurance and Health Insurance coverage lines, Life Insurance Claim and Accidental Death Benefit Claim and Policy Matters where issues of  Guardianship, Conservator, Minor Beneficiaries and different types of Trusts are involved, Trustee Responsibilities and Duties Expert where Trusts are involved, Life Insurance Estate Administration issues, Key Person Insurance, Entity-Purchase, Cross Purchase and Partnerships Buy-Sell Life Insurance issues, Accelerated Death Benefit matters, Standard of Care Expert, Provider Fraud, Health Insurance Contract and Policy Provisions Expert, Health Insurance Contract Interpretation Expert, New HealthCare Reform Rules, Regulations, Protocol and Procedures Expert, Health Insurance Claims, Health Insurance Administration Expert issues and matters, ERISA and Group Benefits, Expert in NAIC & State Insurance Code Unfair Trade and Unfair Claim Settlement practices in the Life Insurance and Health Insurance Industry, Underwriting Standards, Underwriting Protocol and Underwriting Procedures Specialist, Third Party Administration, Expert in Underwriting Rating Standards for a Life Insurance Application, Contestable Investigations Specialist and 2 Year Contestable Period Specialist, Claim Denials Standard of Care Expert, Contestable Death Claims, Life Policy Rescissions and Stranger Owned/Investor and 3rd Party Owned Life Insurance transactions, Fiduciary Responsibilities of Agents and Producers in soliciting, handling, selling, and servicing Life Insurance Policies.

 

Advanced Professional Industry Diploma:

ALHC-Insurance Insider Professional Designation & Diploma Received in November of 2002 – (ALHC stands for Associate, Life & Health Claim Administration) – An International Professional Designation from the International Claim Association (an International and Global Association) in Washington, D.C.

The ALHC Diploma Specializes in the following areas within the Life, Accident and Health side of the Insurance Business:

  • Regulatory and Compliance issues with Life Insurance Companies, Insurance claim, policy and contract administration, Self-Funded and Third Party Administration of Claims and Benefits, Policy and Contract interpretation and adjudication of Group and Individual Life and Health Insurance claims, policies, benefits and coverage’s, Life & Health Insurance Law, Medical aspects of Claims, Claim and Policy Administration of all Life, Accident and Health Insurance Claims and Policy matters, Insurance Licensing Protocol and Procedure, Non-Admitted and Admitted Insurance Company Requirements, Disability Claim matters, Underwriting Protocols and Procedures, Personal and Business Use of Life Insurance, Claim Denial Rules and Regulations specialist, Unfair Claim Settlement Practices and Unfair Trade Practices Statutes and Regulatory Specialist, Claim Department Procedures and Claim Department Guidelines, Third Party Administration and Self-Funded Administrative Guidelines.

I am an Expert on and have actual experience on and within the following areas:

  • NAIC Unfair Claim Settlement Rules and Regulations and NAIC Unfair Trade Practices Rules and Regulations, 2 Year life Insurance Contestable Period Specialist, Claim Denial Specialist, Claim Department Operations and Adjudication specialist of how Life Insurance Companies operate in the Economy, Expert in Claim Department Procedures and Claim Department Protocols, Rules, Regulations and Protocol issues Expert in Claim Handling and Claim Department Operations, Underwriting Best Practices and Underwriting Proper Procedures Expert, Beneficiary issues, Bad Faith Expert, Adverse Claimant situations and proper Claim Handling Best Practices with Insurance Company Claim Departments, Third Party Claim Administrators and Self-Funded and MEWA Plan Administrators, Contestable Claim and Contestable Policy Investigations and Protocol, Policy Rescissions, and the Economic & Benefit Administration and Adjudication and Policy and Procedural aspects of Group Life and Individual Life Insurance & Benefit matters, Absolute and Collateral Assignments and how they affect Life Insurance contracts, benefits and proceeds, Employee Benefits and all Group Life/Employer Sponsored Life Insurance coverage’s and Individual Life Insurance policies, Credit Life and Credit Disability Standard of Care and Proper Claim Handling Procedures, Disability Policies and Disability Claim Administration claim matters, ERISA and Group benefits, Bad Faith Expert, Reinsurance matters, Accidental Death cases, Life Insurance claims and all Life Policy matters, and all aspects of suspicious death cases, homicide cases, drowning death cases, drug-related death cases, and cases of a claimant claiming living or accelerated benefits from a life insurance policy, and Contestable Claim Investigations Specialist, Underwriting Rules, Regulations and Procedure and Ratings Expert.  

Unique Hands-on and Practical Life Insurance Policy Interpretation, Administration and Claim Handling and Claim Adjudication Experience stated below:

  • I am an Insurance Policy, Claim, Administrative and Adjudicative Expert and Life Insurance Protocols and Procedures Specialist who has actually processed, administered and adjudicated thousands of claims for Life Insurance Benefits, who is also an Expert and has extensive knowledge and experience in dealing with and knowing Rules and Regulations regarding Unfair Claim Settlement Practices and Unfair Trade Practices with the Life, Accident and Health Arena, and the entire Application, Bad Faith, Underwriting and Rating Process that Insurance Companies Use to evaluate Life Insurance Applications, NAIC Rules and Guidelines, and Regulatory and Compliance laws and procedures that Insurance Companies must adhere to and follow.

Nationally Recognized as an Insurance Claim, Policy and Administrative Expert and Insurance Protocol and Procedures Specialist as one of the Best Insurance Experts and Special Investigators in the World by AM BEST COMPANY-AM BEST recommended.

Many Hours of Deposition and Testifying at Deposition Experience as an Expert Witness and have Testified in Federal Court as an Expert Witness-Can write detailed Expert Witness Reports and break down and plainly explain difficult and technical industry concepts, terminology, jargon, procedures and protocols so that a Jury and Judge can understand.

Administered, Handled, Examined, Investigated, Adjudicated, Processed and Settled Thousands of Claims for Life Insurance and Accidental Death benefits, and reviewed, examined, analyzed and interpreted over several hundred Life Insurance Contracts and Policies throughout career. In addition, have a thorough understanding of the entire Underwriting and Risk Selection Process, as well as Best Practices and Proper Protocols and Procedures, as well as procedure for Contestable death claim Investigations, Rescission of Life Insurance Policies, and Claim and Policy Administration, and what constitutes Bad Faith and Unfair Claim Settlement Practices with all Life and Health Insurance Policies.
 

Worldwide Listing Recognition and Publications:

Available Upon Request

 

Special Business and Industry Skills Set & Accomplishments:

From 2004-present-
Created and Developed 10 Course Continuing Education Curriculum for Certified Public Accountants at Community College of Philadelphia’s Center for Business and Industry covering the Pension System, Life Insurance Regulations, Policies and Procedures, ERISA rules and regulations, New Healthcare Reform, Wall Street Reform, Life Insurance Policies and Contracts, Medicare and Medicaid Procedures, The Deficit Reduction Act of 2005 and its impact on Medicaid and Medicare, Viatical Settlement Contracts and Agreements, and a course on Ethics in Business, Governmental Affairs and the Financial World, a course on Fraud in the Life Insurance and Health Insurance System, and a course on Life Insurance, Estate Administration and key and critical Beneficiaries issues and concerns.

 

Special and Specific Areas of Expertise in the Insurance Industry:

(A reference for the Legal, Business and Corporate Community, Insurance Companies, and the Legal Community- See Codes and Topics of Expertise and Advanced Knowledge & Capabilities Below):

  • Expertise Below pertains to all Life Insurance matters, Accident and Health Insurance matters and issues, Universal & Proper Agent, Broker and Producer Fiduciary Responsibilities and Standard of Care within Insurance Industry, Fair and Proper Trade and Business Practice by Agents. Brokers, and Producers, Accidental Death benefits matters, ERISA practices, procedures and protocol. Pension matters, Plan Administrator Fiduciary Duties, Annuity matters, and Health, Disability, and Medical Insurance coverage matters and issues, and Healthcare Provider Fraud.
  • Beneficial Interest Contract Protocols and Procedures, Stranger Owned/Stranger Originated Policy and Contract issues, Investor Owned and Speculative Life Insurance transactions, Life Settlement Contractual issues, Viatical Settlement Contractual issues Expert Special Investigator, Trainer, Educator, Investigator, Troubleshooter, and Lecturer to Groups, Organizations, Businesses, Individuals and Families on matters of Economics, Financial and Benefit matters, Estate Planning and Estate Creation, Group Economic Development and Advancement, Group Insurance, Pensions, Annuities, Health Insurance concerns, Business Ethics, Business Administration, Business practices and procedures in Corporate and Government Institutions nationwide.
  • Expert in the investigation, detection and deterrence of fraud and corruption, as well as being an expert in the Benefit and Policy Administration of Corporate Financial & Economic Affairs, Government Benefit matters, Corporate Owned Life Insurance, Group Life and Individual Life Insurance, and Accidental Death benefits, Pensions and Annuities, Individual and Group Economic concerns for families, individuals, businesses and organizations.
  • Skilled expert in conducting Special Insurance & Benefit investigations and preparing detailed special investigative reports for clients.
    • Created and Developed 10-course CE (Continuing Education) Curriculum for Insurance and Financial professionals, Legal Professionals, and CPA’S at local Philadelphia Community College. (Curriculum taught to CPA’s at CCP).
    • Created, Developed and taught Courses on the Economics of Life Insurance and Pensions in the Economy to CPA’S (Certified Public Accountants) at local Philadelphia Community College.
    • Created and developed a course entitled “Ethics in Business, Governmental Affairs & the Financial World” for CPA’S at local Philadelphia Community College.
    • Skilled Insurance Claims Expert.

 

Additional & Other Industry Accomplishments, Certificates, Awards & Education

Received Throughout Entire Career:

  • CFS- (Certified Fraud Specialist)-Obtained Advanced Professional Designation from the Association of Certified Fraud Specialists in Sacramento, CA. (Obtained in March of 2004). Skilled expert and specialist in the investigation, prevention, detection, and deterrence of fraud and corruption in the areas of Corporate & Government Insurance Policy and Benefit Programs, policy and procedural matters, Estate Administration, Life Insurance & Accidental Death Benefit matters & Estate Settlement Matters, Disability Claim matters, Health Insurance matters, Underwriting Procedures and Protocols, Pension benefit matters, and Corporate and Governmental Benefit policies and procedures fraud, and unfair business practices and  unfair claim settlement practices by Insurance Companies with Life and Health Insurance matters and claims.        
  • Obtained Associate Member Designee certificate from the ASSOCIATION OF CERTIFIED FRAUD EXAMINERS, and International and Global organization (Specializing in the detection and deterrence of fraud and white-collar crime in the areas of Corporate, Government Benefit and Insurance matters), July 1999.
  • Obtained Broker License in Life Accident, and Health Insurance for and within the state of Pennsylvania, 1997.
  • Attended Temple University, Real Estate Institute (Received Real Estate Certificate), 1995.
  • Attended Temple University, Risk Management and Insurance and Business Administration program, from 1985-1990.
  • State Farm Automobile Insurance Company in Concordville, PA (Summer of 1990, awarded and chosen for summer internship program).
    • After completing internship at State Farm Insurance Company decided to delve directly into the Insurance Arena by securing employment  as a Disability Claims Examiner and Director of Disability Claims at the now defunct Life and Health Insurance Company of North America in downtown Center City, Philadelphia, and gain valuable claim adjudication and policy product knowledge, as well as continue in future years to pursue hands-on education and training, and professional certifications and professional designations and diplomas through Corporate America Insurance Companies in lieu of continuing and completing a college diploma.

 

Employment & Special Expert/Executive Duties & Independent Contractor & Consulting Projects undertaken since 2002 are listed below:

  • Sep 2002 – Present:  Insurance & Benefits Consultant & Educator to Individuals, Consumers, Clients, Families, Businesses & Non-Profits.
  • 2004 – Present:  Independent Expert Witness & Expert Consultant on Insurance Contracts, Policies & Claim Consultant to Attorneys, Producers, Agents and Brokers. – Insurance & Benefits Instructor, Educator & Trainer to Insurance Agents, Financial professionals, CPA’S and business persons and employees in Corporate America who deal with Insurance products. *Sole Creator and Developer of nearly a Dozen Continuing Education courses for Insurance Agents, Producers, Brokers, CPA’S (Certified Public Accountants), Attorneys, and Financial professionals.  
  • Jan 2011 – June 2012- Served as Instructor and Educator-ISOP (Insurance Society of Philadelphia-Philadelphia, PA)-Conducting Continuing Education Workshops and Seminars for Insurance, Financial, and Legal Professionals. Courses developed and created for these professionals Expert 3560 include courses on both Healthcare Reform of 2010 and Wall Street Consumer Protection and Reform, Stranger Owned Life Insurance Transactions, and Ethics and Product Knowledge in the Group Life Marketplace.
    • Set New Precedent, brought New Thought Leadership and New Strategies at ISOP by bringing Awareness, New Strategies of Development and Expansion into the Life, Accident and Health side of the Insurance Business and Introduced to the Insurance Society of Philadelphia, then Implemented, New courses on the Life, Accident and Health side of the Business that were previously not being undertaken and explored by the Insurance Society of Philadelphia.
  • 2008 – Present:  Current Pre-Licensing and Continuing Education Instructor for Express Education, and Educational Institution providing and teaching Classes for persons who are attempting to obtain and Insurance Producer License, and students who need their required Continuing Education Credits to maintain their Insurance license. I am an Expert in Life Insurance matters, Regulatory and Compliance Issues, Claim and Benefit Administration and Procedures from the Underwriting Process all the way to the Claim Adjudication Process.
  • 2004 – Present:  Educator and Instructor to CPA’s (Certified Public Accountants) for CCP (Community College of Philadelphia, PA)-have created, developed and taught as a Subject Matter Expert (SME) on TOPICS such as the Key Elements with respect to Unfair Trade Practices and Unfair Claim Settlement Practices as promulgated and directed by the NAIC, Stranger Owned/Investor Owned Life Insurance transactions, Contestable Investigations and the Life Insurance Policy and Life Insurance Policy Rescissions, New Healthcare Reform, Wall Street Reform, and key areas within the Life, Accident and Health Insurance arena.
  • 2003 – 2007:  Past Instructor for A.D. Banker and Company educating teaching and training Corporate Executives, Attorney’s, Senior Management, Underwriters, Sales and Marketing staff, and Agents and Brokers in the areas of COLI (Corporate Owned Life Insurance), Business ethics in the Insurance, Financial, & Economic world, fraud training, and product knowledge training in economics and benefits.  In addition, providing training in Group Life Insurance coverages, policy provisions, and new group life products from the group life application process to the claim settlement process. In addition, educating working professionals on FMLA, COBRA and HIPAA coverage’s & benefits.
    • Have conducted throughout career extensive Fraud, Bad Faith, Unfair Claim Settlement and Unfair Trade Practices training and education workshops in the Life Insurance and Accidental Death benefits marketplace to company executives and benefit personnel. In addition, teaching Ethical Responsibility, Employee Benefit and Retirement planning and Financial planning through the use of Individual and Group Life Insurance, Pensions, Annuities and Estate Education.
    • Educator to insurance and benefit employees of small, medium and large employers and businesses on Individual and Group Benefits matters and issues, and Unfair Trade and Unfair Claim Settlement Practices and Unfair Insurance Practices, NAIC Guidelines and many other Regulatory, Compliance and Administration issues in the Life, Accident and Health Insurance Marketplace. In addition, serve as an Educator to Sales Agents, Producers and Brokers to foster better understanding of the Group and individual Benefits, and proper Ethical responsibility and proper client service.
    • Have trained and educated Business Owners, Senior Management, Claim Administrators, Underwriters, and Sales and Marketing staff in areas of detection and deterrence of insurance Fraud in the group life market.
    • Expert in Claim, Policy, and Benefit Administration procedures for Life Insurance, Accidental Death benefit matters, Pensions and Annuities, and Corporate and Government Business affairs.
    • Expert Insurance and Benefits Advisor and Consultant to insurance agents, brokers, financial advisors, attorney’s, business owners, and company executives in helping them understand how these insurance & benefit matters are & should be administered and handled properly.
  • 12/96 – 8/2002   Reliance Standard Life Insurance Company:  Position- Life Insurance Benefits & Accidental Death Benefits Claims Examiner
    • Responsible For the investigation, evaluation, adjudication and settlement of Life Insurance Claims, (from Life insurance Claims of several thousand dollars to Life Insurance Claims in the Hundreds of Thousands of Dollars in accordance and compliance with each States Insurance Department Insurance Rules and Regulations), Life Insurance Law, Best Practices and Proper Standard of Care, and in accordance with Insurance Policy provisions for hundreds of corporations, companies and firms within the jurisdiction of the United States of America.
    • Providing and educating beneficiaries with intricate, lucid explanations of all settlement options in the Life Insurance policy and Estate Settlement process to include all interest rate and beneficiary issues. Extensive Underwriting Education Received.
    • Adjudicated and Administered Absolute Assignments of Life Insurance Benefits, Accelerated and Living Benefits for Policyholders, and educated Policyholders on Viatical Settlement Contracts and how they work.  Major Consultant to Underwriters on how Contestable in Investigations and Policy Rescissions actually work and are adjudicated.
    • Conducting and moderating training sessions and workshops with underwriters, agents and brokers on the Life insurance contract and policy administration how it really works at the time of insured’s unfortunate demise to help improve the risk management and selection process for underwriter, as well as to improve service to clients for the agents and brokers. In addition, skilled expert in investigating and uncovering Life Insurance and Accidental Death benefit administration Fraud.
    • Educating policyholders on Life insurance policy provisions, options, and riders, such as how the Family Medical Leave Act of 1993 as implemented and used in the Life Insurance contract, as well as rules and regulations that affect the Life estate claim for benefits in an Accelerated (living) Benefit Rider claim.
    • Applying applicable ERISA laws in the adjudication of Life Insurance claims.
    • Administered and Adjudicated Life Insurance claims for non-employer/employee groups, including trusts, unions, and partnerships.
    • Provide claim filing instructions to Policyholders and the Insured to aid in the claim administration process.
    • Knowledge of NAIC (National Association of Insurance Commissioner Guidelines).
      • Received the “Achieving Extraordinary Customer and Client Relations Award” during tenure as Administrator.
    • Served as “Critical Incident Troubleshooter” for all Group New Business accounts (i. e Non-profit, For-profit and Trust arrangements) in charge of working with Human Resource departments and Benefits departments in all employee benefit consulting and problem and resolution issues.

 

Additional Corporate and Business Experience

  • 3/94 -12/96   WHYY-TV 12     Fund Raising Representative & Team Leader
  • September1993 – January 1994:  held Group LTD (Group Long Term Disability Claim Analyst) position for John Hancock Life Insurance Company-serving in the Claim Administration Branch office in the Greater Philadelphia area.
  • September 1990 – Summer 1993:  Served as Director of the Individual Disability Claims Department for an insurance company in Philadelphia (Life & Health Insurance Company of North America- in the Heritage Disability Insurance Company claim department) in Downtown Philadelphia. I was responsible for the investigation and adjudication of individual disability claims where 70% of the claimants lived and worked in the state of California.

 

 

 

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