A common reason health care claims are denied is that the service is experimental or investigational. Each health insurance policy defines "experimental" differently, but basically the health insurer is saying hat the treatment is not proven to treat the medical condition the patient suffers from.
These denials can be devastating because the patient may have already exhausted other treatment choices. She may have been told by her treating doctor that this particular treatment is the best one for her particular health condition. These are also very hard denials to overturn because what treatments are "experimental" is generally decided by the health insurer without having to defer to the treating doctor's opinion.
CNN posted a recent article about individuals with serious seizure disorders who want to get ablation surgery - a minor brain surgery to treat lesions on the brain causing seizures. The alternative surgery is much more invasive and dangerous. Aetna, the health insurer for the individuals, denied the claims for ablation surgery, stating that it is experimental.
"The laser surgery is approved by the Food and Drug Administration and is widely recognized within the epilepsy community as an effective treatment alternative to open brain surgery, especially when the location of seizure activity can be pinpointed to a specific part of the brain. Dr. Jamie Van Gompel, a neurosurgeon at the Mayo Clinic, disputes Aetna's assessment. He is not involved in Cara's care nor Rittereiser's treatment, but he said Aetna's assessment is wrong."I would not call it experimental at all," said Van Gompel, who is leading a clinical trial on the surgery at Mayo as part of a larger national study. "It's definitely not an experimental procedure. There've been thousands of patients treated with it. It's FDA-approved. There's a lot of data out there to suggest it's effective for epilepsy."
Read the whole article here: "Girl has blunt message for Aetna after her brain surgery request was denied"
ERISAdvocate
Welcome to the exciting world of ERISA! This blog is written by attorneys Kate MacKinnon and Sarah Demers at the Law Office of Katherine L. MacKinnon. Here, we'll talk about ERISA: updates on employee benefit law, information we hope people who have been denied benefits will find helpful, and any news or tidbits we think should be shared with the world.
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Monday, December 11, 2017
Tuesday, November 14, 2017
Class Action ERISA case against UnitedHealth Group
Medical insurance plans and policies only cover health care that is "medically necessary". Different plans define "medically necessary" in different ways, and health insurance companies often have to come up with some internal guidelines about what type of treatment will be covered for certain conditions, and when different treatment must be sought first.
This is difficult in claims involving mental health and substance abuse. Recently, a class action lawsuit was filed against United Behavioral Health ("UBH") asserting that the guidelines being used to deny claims were not in line with standard medical practice. The plaintiffs allege that UBH guidelines required claimants to receive a lower level of medical care than should have been given to them considering their medical conditions.
Read more here at California Labor Law News: click for article
Friday, September 22, 2017
What is a Life Waiver of Premium benefit?
A "Life Waiver of Premium" benefit - also called an "LWOP" benefit- is a provision that is commonly included in life insurance policies which waives the premiums normally required to maintain life insurance coverage for insureds who are disabled.
This benefit is extremely important to a disabled person because often based on her medical history, she will be unable to obtain life insurance coverage elsewhere in the free market. She also may not be able to return to work and obtain group term life insurance coverage through an employer.
Each life insurance policy that has an LWOP benefit will define "disabled". The insured needs to meet this definition to qualify to have her life insurance premiums waived. Usually the standard for being disabled is very high - for example, being unable to work in any job for any wages.
If you make a claim for LWOP benefits and the claim is denied, or if you were receiving an LWOP benefit and your benefit is terminated, if your claim is governed by ERISA you have the right to appeal that decision. Even if your claim is not governed by ERISA, your life insurance contract may allow you to appeal that decision to the insurer. You may want to hire an attorney to help with that appeal.
Contact the Law Office of Katherine L. MacKinnon for more information!
This benefit is extremely important to a disabled person because often based on her medical history, she will be unable to obtain life insurance coverage elsewhere in the free market. She also may not be able to return to work and obtain group term life insurance coverage through an employer.
Each life insurance policy that has an LWOP benefit will define "disabled". The insured needs to meet this definition to qualify to have her life insurance premiums waived. Usually the standard for being disabled is very high - for example, being unable to work in any job for any wages.
If you make a claim for LWOP benefits and the claim is denied, or if you were receiving an LWOP benefit and your benefit is terminated, if your claim is governed by ERISA you have the right to appeal that decision. Even if your claim is not governed by ERISA, your life insurance contract may allow you to appeal that decision to the insurer. You may want to hire an attorney to help with that appeal.
Contact the Law Office of Katherine L. MacKinnon for more information!
Friday, June 30, 2017
NY Times Article: Spouse's Consent is Required to Change Retirement Account Beneficiary
This article in the New York Times addresses the requirement that a spouse be informed of a change in beneficiary and consent to that change:
"WHY does a married person who has certain kinds of retirement accounts have to get his or her spouse’s permission to change the beneficiary of those accounts?
And why does a married person who is about to start receiving a pension have to get spousal permission to select a payment option that will not give the spouse at least half of those benefits for life if the pensioner dies first?
The short answer to both questions is, because the law says so. A longer answer came when President Ronald Reagan signed that law, the Retirement Equity Act of 1984.
“No longer will one member of a married couple be able to sign away survivor benefits for the other,” Mr. Reagan said, explaining that “a spouse’s written consent now will be required on any decision not to provide survivors’ protection.”
Check out the whole article here
"WHY does a married person who has certain kinds of retirement accounts have to get his or her spouse’s permission to change the beneficiary of those accounts?
And why does a married person who is about to start receiving a pension have to get spousal permission to select a payment option that will not give the spouse at least half of those benefits for life if the pensioner dies first?
The short answer to both questions is, because the law says so. A longer answer came when President Ronald Reagan signed that law, the Retirement Equity Act of 1984.
“No longer will one member of a married couple be able to sign away survivor benefits for the other,” Mr. Reagan said, explaining that “a spouse’s written consent now will be required on any decision not to provide survivors’ protection.”
Check out the whole article here
Monday, November 28, 2016
Kate and Sarah honored as Volunteer Attorneys of the Year by Cancer Legal Line
Kate and I are proud to be honored by the Cancer Legal Line as Volunteer Attorneys of the Year. The Cancer Legal Line does a wonderful job providing legal advice to cancer patients, survivors, and their families. Check our Cancer Legal Line here.
Kate presenting - "Effect of New Administration"
Kate is presenting today on a webcast for Minnesota CLE on the "Effect of the New Administration" specifically on the U.S. Supreme Court. Catch it here if you missed it!
Wednesday, June 1, 2016
Assumptions, Calculations, and Formulas: Are My Benefit Payments Being Calculated Correctly?
The letter finally arrived from the insurance company
letting you know you will begin receiving monthly disability benefit payments. A week or so later, a check arrives in the
mail. The check is in an amount less
than your normal paycheck. You knew
disability benefits were only a percentage of your pre-disability income, so
this is not surprising. You deposit the
check, assuming the insurance company has correctly calculated what you are
entitled to receive. Should you be doing
more to check the amount of the payment?
How the insurance company or plan administrator
interprets your disability insurance policy or plan to create a formula to
calculate your monthly benefit amount can make a significant difference in the
amount of benefits you will receive. The
inputs that determine your monthly benefit are generally: your pre-disability income,
the benefit percentage, and your offsets. But the insurance company decides, based on
the language in your policy, what is considered pre-disability income and what
is an offset. Moreover, the insurance
company/plan administrator decides how these calculations are done and in what
order.
What is the
benefit percentage? Most
policies and plans provide for a disability benefit payment that is a
percentage of pre-disability income.
What percentage is used depends on the policy/plan language and what
elections you made at the time you enrolled in the plan or signed up for the
insurance. Always double-check that the
insurer is applying the correct percentage.
For example, if your policy provides a basic benefit of 50% and an
optional additional benefit of 65%, make sure that you get paid based on the
higher percentage if you elected it and paid premiums for it.
What is “pre-disability
income”? The next step is to define your pre-disability income because
the benefit is going to be a percentage of that amount.
For
many people, calculating pre-disability income is simple. It is the employee’s hourly wage or annual
salary. But for some people, how to calculate
pre-disability income is less clear. For
example, with a salesperson, are his/her commissions “income” or is “income”
only the hourly base wage? Likewise, for
a server in a restaurant, are tips “income?” What about a doctor who teaches a class in
addition to his/her clinical practice, is the money gained from teaching used
to calculate “income?” What about
bonuses? Whether or not these things are
considered as part of pre-disability income could dramatically impact the
amount of disability benefits.
What are “offsets”?
Disability benefit payments will usually be reduced by income the individual
receives from other sources while disabled. Common examples of this would be Social
Security Disability Insurance benefits received by the individual or his/her
dependents, disability benefits from individual policies, or pension benefits.
Your
disability policy defines what income sources are considered “offsets,” and whether
the amount you receive will be reduced by these “offsets.” Sometimes it is unclear whether something you
have received will be considered an offset. For example, if you were disabled because of a
car accident and you received money from a lawsuit based on the car accident,
is that money an offset to your disability benefit payments? What if you had to pay an attorney to
represent you in the lawsuit, will your disability benefit only be offset by
the amount you actually received from the lawsuit or will the attorney’s fee
also be an offset?
The order of operations
is important. The “order of operations” – the order
in which these calculations are done-- also impacts your benefit amount. For example, if your policy increases your
monthly benefit over time to account for inflation (a cost of living
adjustment), is that adjustment applied to your gross benefit (before offsets are applied) or to your net benefit (after offsets are deducted)?
Over time, this can cause a dramatic
difference in the amount of your monthly disability benefit.
The point is…
These are some decisions that are made by the insurance company, based on the
language in the policy, as to how your monthly benefit is calculated. When you begin receiving benefits, if you have
any questions about how your benefit was calculated you can ask the insurance
company for an explanation of how it calculated your monthly benefit amount. If you disagree with how the benefit was
calculated, you may be able to appeal to the insurance company and explain why
your benefit should be calculated differently. If you do not raise a concern about how your
benefit was calculated when you first begin receiving benefits, you might waive
this objection and be prevented from disputing the calculations at a later
date.
Contact
an attorney specializing in employee benefits and ERISA law if you have
questions about whether your benefit was calculated correctly based on the
language in your policy.
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