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Texas Judge Strikes Down Affordable Care Act

Posted Monday, December 17, 2018 by Pivotal Law Group

A federal judge in Texas has ruled the Affordable Care Act (a/k/a “Obamacare”) can no longer be enforced. The judge determined the Act cannot function without its individual mandate requiring virtually all Americans to carry minimum health coverage. Congress repealed the ACA’s individual mandate at the end of 2017.

If the ruling becomes the law of the land, it will have serious implications for health insurance coverage. Among other things, the ruling eliminates the ACA’s minimum coverage requirements including guaranteed coverage for people with pre-existing health conditions, emergency medical treatment, maternity and newborn care, mental health and substance abuse treatment, prescription drugs and pediatric care.

The ruling has the potential to eliminate health coverage for about 17 million Americans — including millions who gained coverage through the ACA’s expansion of Medicaid. Policyholders with pre-existing conditions could see significant premium increases once the ACA’s prohibition against increased charges for pre-existing conditions become void.

For the time being, the ruling has little practical impact for insureds. The federal Centers for Medicare and Medicaid Services emphasized “There will be no impact to enrollees’ current coverage or their coverage in a 2019 plan”. For now, the biggest concern is that the ruling will confuse insureds into failing to purchase coverage during open enrollment, which CMS states will proceed normally.

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"Washington State Supreme Court Rules Against Microsoft in Retaliation Lawsuit by Ex-Employee"

Posted Thursday, November 29, 2018 by Pivotal Law Group

Recently, the Washington State Supreme Court heard a case regarding a former Microsoft Employee “who accused the company of laying her off in retaliation for taking prior legal action in a gender-discrimination complaint”. In 2004, Cornwell the former employee expressed her concerns to her supervisor that her performance reviews may be poor as her manager had been favoring another employee. She was quickly assigned to a new role. However, in 2005, Cornwell began to raise more concerns about her performance reviews claiming that she was being discriminated against as her peers felt she was performing well, but her new manager was reporting otherwise. This led Cornwell to hire an attorney and sue the company based on the discrimination that was taking place. She was eventually able to come to a settlement agreement with the company and was transferred to a new department.

However, a couple years later Cornwell’s new supervisor asked her to mentor an employee who worked under her previous supervisor that committed the discriminatory acts. Cornwell explained that due to the previous events she would not be able to mentor the employee. The senior supervisor and manager ended up giving Cornwell some of the lowest performance rankings yet again, and shortly after she was laid off. Cornwell then “filed a lawsuit alleging Microsoft retaliated against her in violation of the state’s anti-discrimination law”. The ruling sided with Microsoft as they claimed there was not sufficient evidence that “the manager who gave Cornwell a poor score knew about the initial legal action and settlement”. However, the Supreme Court heard the case due to an appeal and this time they sided with Cornwell as the Court concluded there was “sufficient evidence to link her initial legal action to the poor review she received years later and the company’s decision to lay her off”. This decision was significant as it may set “a precedent that employees no longer have to prove company officials had ‘actual knowledge’ of a complaint at the time they took punitive actions against them”, making it difficult for companies to win these cases by simply denying knowledge.

Source: https://www.seattletimes.com/seattle-news/washington-supreme-court-rules-against-microsoft-in-alleged-retaliation-lawsuit/

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Health Insurer Ordered to Pay $25.5 Million For Wrongful Cancer Treatment Denial

Posted Friday, November 9, 2018 by Pivotal Law Group

In a timely followup to last week’s discussion of how to fight health insurance denials, this week an Oklahoma jury ordered health insurer Aetna to pay $25.5 million for denying coverage for insured’s Orrana Cunningham’s cancer treatment bills. Aetna had denied coverage for Orrana’s treatment in 2014 on the basis it was “experimental;” after being denied coverage for this treatment, Orranna passed away the next year.

The case illustrates one of the classic issues in a health insurance or disability insurance coverage dispute. In typical cases, the insured’s family doctor or specialist prescribes treatment or time off work after examining the insured, diagnosing an illness or injury, and identifying appropriate treatment. The insurer typically denies coverage based on the opinions of a physician on the insurer’s payroll; these “file review” physicians usually don’t practice medicine in the conventional sense, but work for the insurer reviewing medical records of insureds to advise the company whether to cover the treatment or disability.

As you could imagine, the doctor on the company’s payroll has a powerful incentive to tell the insurer what it wants to hear, which is typically that there is no coverage and the insurer need not pay for costly treatment. Moreover, the insurer’s physician has no history of treating the patient, virtually never examines the patient, and limits their analysis to a cursory review of the patient’s medical records. In many cases, the physician is so overworked they give little or no attention to the patient’s medical history or treatment needs before denying coverage.

That’s what happened to Orrana Cunningham. In the course of the lawsuit, it came out that Aetna’s doctor reviewing Orrana’s medical records was pressured to review more than 80 patients’ cases a day. The plaintiffs also told the jury Aetna’s file reviewers were unqualified, and were compensated based on Aetna’s profit – not based on getting claims right.

The plaintiffs’ attorney reported a juror approached him after the trial and emphasized the jury “wanted to send a message to Aetna” to fix a broken health insurance system.

Pivotal Law Group attorney McKean J. Evans represents insurance policyholders and has obtained favorable outcomes in disputes with insurance carriers in health care and other insurance disputes. If you have questions regarding a health insurance or other insurance coverage matter, contact McKean for a free consultation.

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How to Fight A Health Insurance Denial

Posted Friday, November 2, 2018 by Pivotal Law Group

Many Americans increasingly find themselves dealing with huge medical bills after medical procedures their health insurers should have covered. All too often, the insurance company says “it’s not our problem, talk to the hospital;” the hospital says “it’s not our problem, talk to your insurer;” and the insured is left holding the bag, often at a time they’re already dealing with the stress of major surgery or illness.

The good news is Washington insureds have specific rights they can enforce to hold their health insurer accountable. Insurers must follow the specific terms of the policy contract and cannot deny coverage for medical bills without a reasonable basis. If insurers fail to live up to their obligations, the insurer has legal rights under Washington’s Consumer Protection Act and Insurance Fair Conduct Act, or the federal Employee Retirement Income Security Act, to seek a court order requiring coverage and requiring the insurer to pay the insured’s attorney’s fees.

Unfortunately, fighting a health insurance denial takes significant time and effort, which can be hard when you’re already recovering from surgery or illness. This is why many health carriers have been criticized for making the process difficult and confusing in the hope that insureds will simply give up without fighting the denial.

There are three common reasons why health insurance claims are denied:

  1. The insurer determines the procedure, treatment or medicine was not “medically necessary.” The definition of “medically necessary” depends on the specific policy, but, generally, when the insurer says the procedure wasn’t medically necessary they basically mean “we don’t believe you really needed it.” Sometimes the insurer uses the same rationale to deny coverage on the basis the treatment is supposedly “experimental.”
  2. The hospital or doctor who provided the treatment was out-of-network, meaning the provider didn’t have a contract with the insurance company. Most health insurance severely limits or eliminates coverage for out-of-network providers.
  3. The doctor or hospital who provided the care used improper billing and coding, causing the insurer to reject coverage because the hospital didn’t properly detail what care was performed.

The good news is many people successfully fight their health insurer’s denial of coverage. Each of the three common reasons health claims are denied can be subject to attack:

  1. Denials on the basis treatment was not medically necessary can often be fought with the support of the doctors who prescribed the treatment or care at issue. Too often, health insurers misread, gloss over, or outright ignore a physician’s rationale for prescribing treatment. Especially where treatment is expensive or time consuming, insurers have a powerful temptation to “miss” the medical records demonstrating the patient needs the treatment in order to justify denying coverage for treatments that will cost the insurer a lot of money.
  2. Denials for out-of-network treatment can be fought by insisting the insurer follow the policy contract and the federal Affordable Care Act (a/k/a Obamacare). Often, the policy contract requires the insurer to provide at least some degree of coverage even where the treatment is out-of-network. Furthermore, if the insured was treated by an out-of-network provider for emergency care, the Affordable Care Act requires the insurer to treat the care as though it was provided in-network.
  3. Improper billing and coding by the hospital can often be challenged by a thorough review of the medical records, procedure codes and billing codes.

Importantly, your insurer cannot deny health care coverage without a reasonable explanation. This means you have the right to know specifically why coverage was denied and to get the information you need in order to fight the denial. Most health insurers are required to allow you to “appeal” the denial before filing a lawsuit.

Lastly, in fighting a health insurance denial, be mindful of the applicable deadlines. All health insurance disputes are subject to deadlines that will cause the insured to lose their right to challenge the health coverage denial if the insured fails to act within a certain time period. The specific deadline varies, so it is critical to be diligent and stay aware of any applicable deadlines when fighting a health coverage denial.

Pivotal Law Group attorney McKean J. Evans represents insurance policyholders and has obtained favorable outcomes in disputes with insurance carriers in health care and other insurance disputes. If you have questions regarding a health insurance or other insurance coverage matter, contact McKean for a free consultation.

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Washington State Insurance Commissioner Fines United Healthcare for Denying Women's Health Claims

Posted Thursday, October 18, 2018 by Pivotal Law Group

On September 13, 2018, Washington’s Insurance Commissioner entered into a Consent Order with United Healthcare regarding violations of Washington insurance law governing women’s health claims. United Healthcare is a health care service contractor that sells individual and family health insurance coverage.

The Insurance Commissioner’s investigation was prompted by a consumer complaint that United Healthcare improperly denied coverage. According to the complaint, United Healthcare told the consumer her claim was denied because she needed a referral for the women’s health services she received.

That violated Washington’s Direct Access law, which gives women the right to access women’s healthcare from the provider of their choice without having to obtain a referral.

In the course of the investigation, United Healthcare admitted it improperly denied similar claims for 276 insureds. As a result, many women were improperly told they needed a referral in order to obtain coverage for medical treatment.

The investigation is a reminder to insureds to know their rights under Washington law, and to carefully scrutinize coverage denials to make sure the insurer followed the law.

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