ERISA Disability and Health Case Histories and Random Musings by an ERISA Disability Lawyer

Mark Twain said, "Write what you know."   Over the past 25 years, I have handled just about every kind of long term disability claim denial case there is, everything from heart attacks, strokes, cancer, diabetes, fibromyalgia, degenerative disc disease, accidental injury, IBS, headache syndromes, broken eardrums, diabetes  to somatoform disorder.  I have also handled numerous health benefit claim denials for medical providers.

 

All ERISA claims have two things in common: (1) The facts of each case are unique; and (2) the law is always the same (until it changes).  So I thought it might be interesting to take some histories from the cases I know best, my own, and write a short blog post for each one.  Although each one is different, the same issues surface again and again. It seems insurance companies can only come up with so many ways to screw over claimants.   After a couple of decades, a lawyer can get pretty good at identifying the pattern.  Read through the posts that interest you.  And you too may see the patterns I see every day.  I have only included full client names in those cases that were litigated; and thus, are a matter of public record.

 

Also, from time to time, I may throw in some commentary about the practice of law in general and some perspectives about the life of a sole practitioner ERISA lawyer. 

We only promised to pay you but we never said how much.

Lindsey S. (Empire Blue Cross Blue Shield) Lindsey S. was admitted to the hospital with a diagnosis of Depression. Two weeks prior to admission, her inpatient benefits were verified payable at 70% of “usual, reasonable & customary” (URC) charges, subject to $200 deductible and a $2000 Out of Pocket (OOP) maximum, then payable at 100% thereafter, subject to a 60-day inpatient limit. The day before admission the hospital called Empire a second time, spoke to a different individual and re-verified benefits. Magellan Behavioral Health, Inc. (Magellan) performed “utilization review” services for Empire. During the course of Lindsey’s hospitalization, Magellan issued eight separate certificat

Insurance company CYA after royal run-around

Pacific Shores Hospital vs. Ernst & Young Medical Plan CV 08-5798 DSF (Aetna) The patient received inpatient treatment for major depression at Pacific Shores. A timely claim for benefits was submitted to Aetna. Aetna initially refused to pay the claim, without any explanation. Pacific Shores was later told, during a telephone conversation, that all of the treatment had been disallowed on grounds that treatment was “no medically necessary” and because there was “no authorization on file”. But Aetna never formally notified Pacific Shores or the patient, in writing, of either the claim denial, or the specific reasons for the denial. Therefore, Pacific Shores had to “fly blind” into a claim

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ERISA Disability Lawyer

© 2014 by Michael A. McKuin

Attorney at Law

Post Office Box 10577

Palm Desert, CA 92255

(California State Bar No. 103328)

 

The information provided at this website is intended for educational and promotional purposes only. It is strictly general in nature and under no circumstance should it be considered legal advice.  Every case is unique and a competent, qualified lawyer must be consulted for legal advice regarding any specific case.