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.

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.

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

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/.

There is a growing practice by health insurers to pursue medical providers for a refund of monies paid on past claims.  The insurers typically start their alleged “overpayment” efforts with audits or ”post payment reviews” of the medical providers’ prior billing on previously closed and paid claims.  The medical providers have more defenses available to them than they realize, and they should employ specially qualified counsel to either resist such audit requests or have qualified counsel manage the process.

In the vast majority of situations, the health insurers have no entitlement to a refund whatsoever. For example, if the medical provider is out of network, there is no contractual or other legal obligation to undergo the audit.  However, the request by the insurer can indeed provide the medical provider with an opportunity to actually investigate the insurer, instead of having the insurer investigate the medical provider.  If the insurer is simply attempting to use the process to intimidate the medical provider, a well-informed and proper response by qualified legal counsel can set things back on track between the provider and the insurer.  Even if there are real issues of concern, there are ways to use the tools provided by ERISA (employee benefits law and regulations) to uncover the issues and resolve the problems.

Medical providers should know that they have much more leverage in this context than they realize.  With the help of experienced health insurance lawyers to identify the issues and their defenses, the medical providers can maximize their chances of success.

Quadrino Schwartz is also on the cutting edge in this area of health insurance law and has a track record of success in defending medical providers facing retrospective reviews / audits.

The American Association for Justice recently published an extensive report listing the Top Ten Worst Insurance Companies In America; and considering all of the big names on this list, you should not be surprised to find your company on there.

Beginning with Allstate and ending with Liberty Mutual, with companies such as AIG, Conseco, WellPoint and Farmers in between, the list is a comprehensive and detailed report built on research and investigation of court documents, FBI records, state investigations and more. This is no late night TV show top ten list, but 29 pages packed with disturbing information.

As you read through the report, underlying the frustration and anger is a sinking feeling that this is a David and Goliath situation. As the insured, you’re likely to feel trapped, especially after reading about things such as the Powerpoint slide prepared for Allstate which features “an alligator and the caption ‘sit and wait’—emphasizing that delaying claims will increase the likelihood that the claimant gives up. According to former Allstate agent Shannon Kmatz, this would make claims ‘so expensive and so time-consuming that lawyers would start refusing to help clients.’”

If it was only one corrupt insurance company about which we were reading, it wouldn’t be so disheartening. But a list of ten (and you can be sure these ten aren’t the only ones employing the tactics of ‘deny, delay, defend’) indicates that it’s not an anomaly but a business model. These companies profit from lying, evading and taking advantage of their policyholders. It’s a situation that cannot continue.

Luckily the report isn’t all gloom and doom. The bad is tempered with the good, if you know how to see it, as with this quote about Unum, listed as the second worst Insurance Company, “Despite doctors’ orders to stop working, Unum told [the insured] he was not disabled and could still work—a decision the U.S. Ninth Circuit Court of Appeals would later describe as ‘defying medical science.’” It is shocking to read about the reprehensible acts of these insurance companies, but encouraging to read that judges and juries do side with the insured in many cases, ordering the insurance companies to pay what they have promised.

Cases can be won. Change can be made. And you can get your claims paid. Our firm specializes in taking on Goliath, and we’re dedicated to helping you get the security you deserve.

As a result of the recent spate of hurricanes, wildfires, floods and tropical storms, U.S. residents—and their insurance companies—have had their share of natural disasters and the clean-up and rebuilding that follows. Unfortunately, homeowners and commercial property insurance policies are not always clear regarding whether the damage caused by these natural disasters is covered, and insurance carriers are increasingly exploiting the language in these policies to attempt to avoid liability for these losses.

After Hurricane Katrina, many Louisiana residents found themselves without insurance coverage based upon their homeowner’s policy’s “flood” exclusion. Although both the trial court and intermediate appellate courts ruled in favor of the insured homeowners by finding the exclusion to be unambiguous and inapplicable to man-made events such as the failure of a level, the Louisiana Supreme Court reversed the decision and ruled in favor of the insurance carriers by finding the “flood” exclusion unambiguously applied to both natural and man-made floods in Sher v. Lafayette Insurance Company, __So.2d___, 2008 WL 928486 (La. 2008).

But Hurricane Katrina victims aren’t the only ones fighting with insurance companies to define and receive coverage for damages from natural disasters. CNN’s Money Magazine, in its article entitled Insurers Playing Rough, discusses a disturbing trend by insurance carriers to make lowball settlement offers to their insureds following natural disasters, thereby exploiting the insured’s financial vulnerability in order to avoid paying the total value of their legitimate claims. As detailed by Money Magazine, the carriers offer far less than the claims are worth because many of their insureds who have had their homes and businesses destroyed are desperate to rebuild their lives and will accept paltry settlements to survive.

Homeowners wonder what they can do if their insurance companies deny their claims or give lower payouts than what they feel is deserved. Although the Money Magazine article mentioned above gives some suggestions, your best opportunity to receive the financial coverage you deserve comes from having an experienced professional on your side. Our firm is experienced in negotiating with insurance carriers, has extensive knowledge concerning the intricacies of insurance law, and—unlike your insurance carrier—we always have your best interests in mind.

There is reason for optimism for insured individuals receiving treatment for a mental illness or substance abuse problem. The President just signed into law a bill that was 10 years in the making. It will “require that group health insurance coverage for mental illness and substance abuse be provided on the same terms as coverage for physical illnesses.” Although the bill will not require that mental illness and substance abuse coverage be added to group health plans, it will require that existing coverage for psychological illnesses be no more restrictive than coverage for physical illnesses.

The Bill passed in the House of Representatives by a large margin, and was approved by the Senate. On October 3, 2008, President George W. Bush signed it into law. The act is known as “The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act.” Congress joined the parity bill with the Emergency Economic Stabilization Act, the legislation created to address the economic crisis. The Senate passed the same version of the act earlier in the week.

Whether it’s the current state of the economy, or a maturity difference between the generations, many parents are finding that their children are living at home longer than earlier generations have—and often continue to need the benefits and protections that come with that, including health care coverage under their parents’ medical insurance plans. Now the state of Connecticut has just made it easier for parents to continue providing those benefits and protections to their adult children.

Effective January 1, 2008 in the state of Connecticut, parents will be able to keep unmarried dependents under the age of 26 covered under their own individual or group health plan. Although many health insurance plans already extend coverage for dependents over the age of 18 who are still attending college, the coverage terminates if the child graduates or stops attending school. This situation leaves such adult children and their parents with the difficult decision of choosing whether to pay for more expensive or less than comprehensive coverage, or to risk going without health insurance and paying for medical care as needed, which is always a risky prospect.

With so many children living at home longer, requiring more years to finish school, and facing challenges after graduation in an extremely competitive job market, parents found that the cost of their child’s health care was becoming more and more of a hardship. Although most kids between the ages of 19 and 26 are fairly healthy and don’t anticipate recurring medical expenses, the exorbitant cost of medical care in the event of an unforeseen accident left many parents reluctant to leave their post-college children uninsured. This new Connecticut law will ease the financial burden of obtaining health coverage for adult dependent children.

For more information about state-by-state health insurance coverage for young adults, click here.