Filed:

April 4, 2013 in U.S. District Court in Portland

Plaintiff:

Lorraine and Charles Bates; Eileen Burk, and David Youngbluth

Defendant:

Bankers Life and Causualty Company, CDOC, Inc., CNO Financial Group, Inc., Conesco Life Insurance Company of Texas, Doe Corporations I-X and James D Peterson

Case Number:

3:2013cv00580

Details:

The four plaintiffs filed the suit against Bankers Life on the grounds that the insurance company committed elder abuse by wrongfully denying and delaying long-term care insurance claims and raising premiums without improving benefits. The suit also alleges breach of contract, breach of promises, fraud, negligence and intentional misconduct.

The suit is currently seeking a judge’s approval to represent a class of 9,000 people in the state of Oregon.

According to Lorraine Bates, Bankers Life claimed the adult foster home Bates moved into in 2009 didn’t match policy requirements. The Oregon Insurance Division, however, said in 2011 that Bankers would pay her claim, 19 months after she first filed it.

David Youngbluth decided to take legal action after trying to file a claim for his mother in 2008, who moved into assisted living after a fall. According to Youngbluth, Bankers still owes him three months’ worth of unpaid benefits.

The lawsuit also claims that Bankers sold policies without disclosing large premium hikes without a similar increase in benefits. According to Eileen Burk, her premiums nearly doubled in 2010.

Filed

January 30, 2013, in the Boston federal court.

Plaintiff

Richard Feingold

Defendant

John Hancock Financial Services

Case Number

1:2013cv10185

Details:

Richard Feingold filed a class action suit against John Hancock Financial Services on the grounds that the life insurance company doesn’t work hard enough to pay out life insurance benefits. According to the lawsuit, the life insurance company regularly used the Social Security Administration’s master death list to check whether annuity holders had died in order to halt insurance payments. However, the company failed to routinely use the list to see if policy holders had died in order to promptly pay beneficiaries.

According to Feingold, his mother had purchased a life insurance policy in 1945 and died in 2006. However, Feingold, who was the beneficiary of the policy, didn’t receive the benefits until 2010 when he discovered them on the Illinois Treasurer’s unclaimed property website. Feingold filed the suit on behalf of himself and others whom Hancock had failed to notify of life insurance benefits.

This lawsuit follows a recent settlement by John Hancock and other major insurers on a lawsuit filed by the government for similar allegations. Hancock agreed to pay a settlement of $13 million dollars and to use the Social Security database more frequently to search for unpaid beneficiaries.

Congress has the right to pass a law that actually wipes out all other laws that could come into conflict with the new federal law.  That’s what Congress did with ERISA, and the supremacy of the federal law is called “pre-emption.”

ERISA’s broad pre-emption arises in a number of different situations.   For example, if a person suffers injury (or even dies) from a denial of medical care because an HMO or health insurer denies claims, any legal claims that could be made under State law are wiped out.  The injured person (or their estate, if deceased) is limited to only the remedies that can be found in ERISA, if any.

But there are positive aspects to preemption.  For example, we are pressing the case that ERISA preempts many of the rules and laws that health insurers and health plans seek to use against medical providers, arguing that the rules and laws are preempted.

The U.S. Supreme court has written much on the subject, and federal appeals courts have followed the principles laid down by the Supreme Court in a number of cases.

Stay tuned to this blog for further updates as to how these principles come into play to aid medical providers in their disputes with health insurers and health plans.

In the ongoing battle surrounding audits by health insurers of medical providers, health plans and health insurers are now employing the unlawful technique of offsetting.  This involves the health insurer issuing EOBs that show that payments would be due — but no check is issued — because the insurer offsets the payments with debt it alleges to be due in connection with a past audit.  These are prohibited and unlawful acts under the Employee Retirement Income Security Act (“ERISA”).

Health insurers are typically unaware that they are “claim fiduciaries” under ERISA.  When they process and handle health insurance claims, they are dealing with ERISA governed benefits under employee benefit plans.   Thus, ERISA is the governing law.  Health insurers have been engaging in conduct that they either don’t know is unlawful or do not think that the medical providers will hire ERISA experts to discover their illegality.

We are pressing these issues throughout the United States, with great success, on behalf of medical providers facing audits and various associated aggressive and unlawful tactics by health plans (self-insured) and health insurers (insured plans).

For more information, contact Richard Quadrino at rjq@quadrinoschwartz.com or by calling him at 1-800-745-1755.

Many health insurers who have conducted post-payment audits of medical providers and decided that money is due to repaid to the health insurer have unilaterally decided to stop all payments to the provider.  This “hijacking” of current claims is nothing more than an effort to extort a repayment from the medical provider for alleged “overpayments”.

The hijacking causes even more legal problems for the health insurer.  In the first instance, the post-payment audits in the commercial insurance arena are typically prohibited. Demands for repayment due to alleged “overpayments” are usually not authorized under ERISA governed health plans.  Thus, the demands for repayment are unlawful.  By stopping all claims payments after an audit, the health insurers are merely compounding their legal troubles and subjecting themselves to various remedies.

Medical providers who have the proper ERISA counsel can stop this unlawful activity by the health insurers.  ERISA provides for an injunction to be issued by a federal judge to stop practices and acts that are unlawful under ERISA.  A federal court can also direct that all unpaid claims be paid immediately.

For more information, contact Richard J. Quadrino of Quadrino Schwartz at rjq@quadrinoschwartz.com or by calling him at 1-800-745-1755.

Most medical providers are not aware of their ability to use ERISA to protect and enhance the profitability of their practice.  Having proper counsel on your side is essential to addressing problems with commercial payors or administrators for all privately funded health plans.

Richard Quadrino of Quadrino Schwartz is assembling teams of attorneys across the country. The firm is contributing its many years of successful ERISA litigation and claims experience to these teams.  In addition, Quadrino Schwartz brings decades of insurance industry claims, litigation, and class action experience to the endeavor.

With Quadrino Schwartz on the team, the group and their clients can use all of the ERISA and insurance industry legal tools available to address health insurer refund requests and audit requests.  These legal teams also pursue denied claims where the claim denials are governed by ERISA.

For more information, see http://www.quadrinoschwartz.com/pages/health-insurance-attorneys

The various Blue Cross Blue Shield entities are contacting doctors all over the United States seeking to conduct “audits” or “retrospective reviews” on health insurance claims that have already been paid to the doctors, long ago.  These audits do not involve allegations of fraud, but rather efforts by Blue Cross Blue Shield to attempt to recoup monies that they believe they should never have been paid in the first instance.

Richard Quadrino of Quadrino Schwartz is involved in resisting and defeating such audit and “recovery” efforts by health insurers.  He is working with groups of attorneys across the country, lending his experience in ERISA litigation and claims and using the various legal tools available to address these refunds requests and audit requests.

For more information, see http://www.quadrinoschwartz.com/pages/health-insurance-attorneys

A California appeals court decided to take a second look at its opinion in a case against health insurer Blue Cross Blue Shield.  The insurance company had asked the entire group of appeals court judges in California to review the case.  That request was denied, but it prompted the second review.  In the Court’s prior decision, the Court ruled in favor of a woman suffering from anorexia nervosa by ruling that Blue Cross had to pay for her inpatient treatment.

One key part of the prior decision was the Court’s conclusion that Blue Cross could not raise a defense of medical necessity in court because it failed to raise it during the claims process. While the Court revised its analysis on another, unrelated point, it left unchanged the key ruling as to the forfeiture of untimely asserted defenses.

Quadrino Schwartz is pressing this issue and others in the health insurance arena on behalf of medical providers and hospitals on their denied health insurance claims.

For more information contact Richard J. Quadrino at rjq@quadrinoschwartz.com or call 1-800-745-1755.

The United States Court of Appeals for the 5th Circuit ruled in favor of a health plan’s HMO member and against Aetna regarding a claim for out of network benefits.  In an extensive opinion, the court ruled against Aetna on various legal issues that could set a precedent for the benefit of health plan members under HMOs and other plans nationwide.

The Court, in Koehler v. Aetna, first ruled that Aetna’s summary of the health plan violated ERISA, the federal law that governs most group health insurance in the United States. The language was difficult, vague, and confusing, so the court ruled that any benefit of the doubt when interpreting the summary should go to the plan member and not Aetna, the drafter of the unlawful summary. The Court then ruled that pre-approval for certain medical services was not required because the pre-approval terms in the plan’s summary were not clear and understandable, in violation of the ERISA regulations.

The Court also barred Aetna from raising late defenses and indicated that the plan member did not have to appeal Aetna’s denial because of the regulatory violations.

Quadrino Schwartz is in the forefront in representing medical providers and hospitals in pursuing denied health plan claims and addressing “audits” on closed and paid claims.  For more information, please contact Richard J. Quadrino at 1-800-745-1755 or at rjq@quadrinoschwartz.com.

Long term care insurance  companies will often request a field visit: an in-home assessment by a nurse to evaluate what types of assistance is needed by the long term care patient.  These visits are typically not required under the terms of a long term care insurance policy, but claimants often agree to have these visits take place.  The claimants and their families should be aware, however, that testing or rehearsal of various Activities of Daily Living are actually improper Functional Capacity Evlauations.

Functional Capacity Evaluations are improper for a variety of reasons.  First, the ability to perform a function on one occasion, for a few seconds, does not mean that a person can repeatedly perform that function on an hourly or daily basis.  There are published journal articles — internationally — that have commented upon the limited or poor level of usefulness of such tests.  Second, the particular test or command requested usually seeks a person to use an infirm or compromised body part or mechanism and the claimant may be hesitant or fearful of injury or pain and then can be easily accused of  what the insurance companies call “sub-maximal effort”.  And finally, there is a possibility of injury during these exercises and the long term care insurance company is unlikely to take financial responsibility for any injuries.

Claimants with long term care insurance claims should be armed with legal knowledge as their rights and as to what is proper or improper in the handling of their long term care claims.  You can contact us with any questions at http://www.quadrinoschwartz.com/contact/.