Comments on: Post-script to bureaucracy, now-found documents and health insurance. . . http://dangerousintersection.org/2007/06/11/post-script-to-bureaucracy-now-found-documents-and-health-insurance/ Human Animals at the Crossroads of Culture, Science, Religion and Media Fri, 21 Nov 2008 14:13:42 +0000 http://wordpress.org/?v=2.6.3 By: Tim Hogan http://dangerousintersection.org/2007/06/11/post-script-to-bureaucracy-now-found-documents-and-health-insurance/#comment-12984 Tim Hogan Wed, 13 Jun 2007 17:35:50 +0000 http://dangerousintersection.org/?p=1371#comment-12984 Since the plan which your friend has is employer provided, there is a likely application of the ERISA law. Under ERISA, denied benefits may be sued for in federal court by the insured but, all you get is the not provided for benefit and maybe your attorney's fees (not required). I've filed such suits on behalf of families which have had members with MS, which is a neurological disorder, where the insurer argued there was an exhaustion of a lifeltime limit of psychiatric care and denied benefits. We argued successfully to the insurer that the condition was a medical condition but, were only paid in settlement the amount of the uncovered expense. I had to negotiate with the provider to decrease their lien so as to pay my attorney's fees because I didn't see the fairness of making my client pay me to get something which they were already entitled to by contract. In your friend's situation, if they can work something out with the employer/provider in advance to accept the payment from the proceeds of a suit and have the insurer tell them also the names, addresses, policy numbers, policy language and phone numbers of all similarly situated persons which they declined coverage for orthagnic surgeries where they were caused by birth defects, someone might be able sue the insurer on behalf of all the persons denied such coverage and sock it to the greedy scum. I only got the money for my client when I sent the insurer a request for that exact infomation for any other persons which the plan had denied coverage of medical bills where the person suffered from MS and the company claimed the lifetime limit was exceeded. I don't do that work any more because it's only in federal court, so time consuming and you can't always get providers to waive part of their liens to get paid. I ate several of those and couldn't afford any more. The insurer offers the amount of the benefit, no fees and you have to take the offer to your client and the client has to take it but, you might not get paid which creates a potential conflict of interest. The situation may only be realistically fixed by requiring insurers to pay fees when they improperly and wrongly deny coverage or a class action, if allowed under federal law(I don't know). Certainly, this is not any legal advice to your friend or any other but, if you get the right folks fighting for you it sometimes helps. Since the plan which your friend has is employer provided, there is a likely application of the ERISA law. Under ERISA, denied benefits may be sued for in federal court by the insured but, all you get is the not provided for benefit and maybe your attorney’s fees (not required).

I’ve filed such suits on behalf of families which have had members with MS, which is a neurological disorder, where the insurer argued there was an exhaustion of a lifeltime limit of psychiatric care and denied benefits.

We argued successfully to the insurer that the condition was a medical condition but, were only paid in settlement the amount of the uncovered expense.

I had to negotiate with the provider to decrease their lien so as to pay my attorney’s fees because I didn’t see the fairness of making my client pay me to get something which they were already entitled to by contract.

In your friend’s situation, if they can work something out with the employer/provider in advance to accept the payment from the proceeds of a suit and have the insurer tell them also the names, addresses, policy numbers, policy language and phone numbers of all similarly situated persons which they declined coverage for orthagnic surgeries where they were caused by birth defects, someone might be able sue the insurer on behalf of all the persons denied such coverage and sock it to the greedy scum. I only got the money for my client when I sent the insurer a request for that exact infomation for any other persons which the plan had denied coverage of medical bills where the person suffered from MS and the company claimed the lifetime limit was exceeded.

I don’t do that work any more because it’s only in federal court, so time consuming and you can’t always get providers to waive part of their liens to get paid. I ate several of those and couldn’t afford any more. The insurer offers the amount of the benefit, no fees and you have to take the offer to your client and the client has to take it but, you might not get paid which creates a potential conflict of interest. The situation may only be realistically fixed by requiring insurers to pay fees when they improperly and wrongly deny coverage or a class action, if allowed under federal law(I don’t know).

Certainly, this is not any legal advice to your friend or any other but, if you get the right folks fighting for you it sometimes helps.

]]> By: Mary http://dangerousintersection.org/2007/06/11/post-script-to-bureaucracy-now-found-documents-and-health-insurance/#comment-12979 Mary Wed, 13 Jun 2007 01:01:27 +0000 http://dangerousintersection.org/?p=1371#comment-12979 I had a temp job doing filing in an insurance agency once. Mercifully, it only lasted a few weeks. While there, I heard one of the workers advise another insurance person on the phone NOT to tell a pregnant woman what was covered and not covered in her policy so they could deny her at will. I wouldn't put any policy denial down to an accidental oversight after hearing that. I had a temp job doing filing in an insurance agency once. Mercifully, it only lasted a few weeks. While there, I heard one of the workers advise another insurance person on the phone NOT to tell a pregnant woman what was covered and not covered in her policy so they could deny her at will. I wouldn’t put any policy denial down to an accidental oversight after hearing that.

]]> By: grumpypilgrim http://dangerousintersection.org/2007/06/11/post-script-to-bureaucracy-now-found-documents-and-health-insurance/#comment-12976 grumpypilgrim Tue, 12 Jun 2007 16:46:54 +0000 http://dangerousintersection.org/?p=1371#comment-12976 I once had my own run-in with an evil health insurance company. The saga is too long to explain (the letter I sent to the company describing their long series of screw-ups was nearly four pages long), but the gist is that they had a policy that had already cheated a number of other people and it was still in place when they tried to cheat me with it. The solution is to document everything, to write letters to key officers of the company, and to "cc" everything to the state insurance commissioner and the state office of consumer protection. In extreme cases -- such as when the insurance company has already cheated other people and is still doing it -- a threat to contact the media can also get attention. I once had my own run-in with an evil health insurance company. The saga is too long to explain (the letter I sent to the company describing their long series of screw-ups was nearly four pages long), but the gist is that they had a policy that had already cheated a number of other people and it was still in place when they tried to cheat me with it. The solution is to document everything, to write letters to key officers of the company, and to “cc” everything to the state insurance commissioner and the state office of consumer protection. In extreme cases — such as when the insurance company has already cheated other people and is still doing it — a threat to contact the media can also get attention.

]]> By: Erich Vieth http://dangerousintersection.org/2007/06/11/post-script-to-bureaucracy-now-found-documents-and-health-insurance/#comment-12971 Erich Vieth Tue, 12 Jun 2007 04:07:48 +0000 http://dangerousintersection.org/?p=1371#comment-12971 I'm tired of being patient with insurance companies. Let's reinvoke the "eye for an eye" rule. If a medical insurance company employee wrongfully denies you coverage for fixing a broken leg, let's break that employee's leg. That will get them paying better attention to the full language of the relevant insurance provisions. I'll confess that I worked as an attorney for insurance companies for many years. That company wrote the provision in question. Any potential ambiguity as to how to interpret it should be construed against the insurance company. But there is no ambiguity here, based on what you write. This is clearly a birth defect and the exclusion doesn't apply to birth defects. Sounds like the insurance company denial is meritless. Do update us with the result. I’m tired of being patient with insurance companies. Let’s reinvoke the “eye for an eye” rule. If a medical insurance company employee wrongfully denies you coverage for fixing a broken leg, let’s break that employee’s leg. That will get them paying better attention to the full language of the relevant insurance provisions.

I’ll confess that I worked as an attorney for insurance companies for many years. That company wrote the provision in question. Any potential ambiguity as to how to interpret it should be construed against the insurance company. But there is no ambiguity here, based on what you write. This is clearly a birth defect and the exclusion doesn’t apply to birth defects. Sounds like the insurance company denial is meritless. Do update us with the result.

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