In January of 2018, Judge Lawrence O’Neil issued a scathing ruling against Sun Life Financial, finding that it acted arbitrarily and capriciously when denying Ms. Vicki Young’s claim for ongoing disability benefits, and awarding said benefits to the Plaintiff, Ms.Young.

Ms. Young is a 62-year-old former mortgage broker who suffers from a severe form of fibromyalgia, and several other co-morbid conditions. After paying her LTD benefit for several years, Sun Life decided to terminate her benefit, arguing that the independent physician to whom Sun Life sent Ms. Young concluded that Ms. Young was able to return to a sedentary job, and that Ms. Young’s own physician agreed with that conclusion.

Judge O’Neil agreed with Kantor & Kantor’s argument – on Plaintiff’s Ms. Young’s behalf – that not only did Ms. Young’s treating physician support her disability claim (and was merely confused by an intentionally misleading form), Sun Life’s own independent physician actually gave restrictions and limitations which precluded Ms. Young from returning to applicable work under the terms of the policy.

Today, in our second Mental Health Awareness Month (“MHAM”) blog, we feature a story shown on April 23, 2018, on NBC Nightly News. The story features the Binion family who lost their son Jordan (“Jordy”) to suicide shortly after Jordy declined further treatment for his mental health issues. Unfortunately, even when families desperately want their child to receive treatment, some state’s laws give deference to a minor’s “right to choose.”

Beyond the Binion’s tragic loss, the NBC new piece shared a few very alarming statistics:

  • 40% of states within the U.S. have laws in place that allow minors as young as 12 to affirm or decline consent for mental health treatment;

Insurance is our safety net.

It’s our protection against the unthinkable. Our first line of defense when something goes wrong. Our safeguard for our health and our finances. Our security for our family and our homes. Our precaution against all the “what ifs.” Our surety in protection of our resources and access to healthcare and treatment.

On paper, health insurance sounds pretty anticipative and hopeful. It sounds like if an illness or tragedy were to strike, things would be okay in the end – because someone would be there to catch you. But the harsh reality seems to be a security net with many holes and many flaws. In the hands of insurance companies, so many people seem to be falling through the holes of the net, slipping through the worn out spaces, and some even missing the net completely as they fall.

Each year millions of Americans face the reality of living with a mental illness. May is Mental Health Awareness Month (“MHAM”) and is used to educate and bring awareness to the issue of mental health. During MHAM, Kantor & Kantor will share a series of blogs about various issues and topics related to mental health and highlight important figures and organizations within the mental health community.

We launch our blog series by sharing three short videos featuring The Honorable Patrick J. Kennedy. The Honorable Mr. Kennedy represented Rhode Island’s 1st District in the U.S. House of Representatives from 1995 until 2011. During his congressional tenure, he became one of the nation’s leading voices on mental illness, addiction, and other brain diseases, including he bravely shared about his personal battles with addiction. As a champion to end medical and societal discrimination against all mental illnesses, The Honorable Mr. Kennedy was a lead sponsor of The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”).

Two years after leaving Congress, The Honorable Mr. Kennedy founded The Kennedy Forum, an organization focused on advancing the current ideas, policies, and programming in behavioral health known to be effective, while shining a light on the solutions of the future. To learn more about The Kennedy Forum, please visit: https://www.thekennedyforum.org

Doctor support is critical to patients getting the health benefits they deserve. In health claims, we often see patients who are seeking medication or treatment that is deemed “experimental” or “investigational” by an insurance company, even though other insurance companies may approve the same medication or treatment. The claims that succeed are those that have stellar doctor support. Doctors want to help but need direction. Here are some pointers for patients to get doctor support for health claims.

First, get it in writing. The doctor may have mentioned to you that studies have shown that the recommended treatment is appropriate for your condition. That’s not enough, you need it in writing. Make an appointment with the doctor or his office manager. Explain that you are asking the insurance company to pay for treatment that the doctor has prescribed for you and that you need a letter of support. Most doctors are happy to provide a letter explaining their treatment recommendations.

Second, address the insurance company’s specific concerns. If the insurance company is claiming that the treatment or medication is FDA approved for other conditions, but not your condition, give facts and argument that explain why it is appropriate for your condition. Provide studies (by reference or attach copies) that support your argument. Obtain letters from other patients with the same condition who received benefits for the same treatment.

The Affordable Care Act (often referred to as “Obamacare”) put mental health care on par with physical health, at least as far as health insurance goes.  The reality facing many people in California, however, is that insurance does not automatically mean providers are available. A recent report released by the Healthforce Center at the University of California San Francisco reported the following statistics:

  • Approximately one in six adults in California were diagnosed with a mental illness in 2014, while one in twenty-five had a serious mental illness
  • One in fourteen children in California had a serious emotional disturbance

California Department of Insurance Commissioner Dave Jones has opened an investigation into allegations that health insurer, Aetna, denies insureds’ claims and requests for prior authorization for medical care without ever reviewing medical records. Although Aetna’s improper utilization review practices come as no surprise to the attorneys at our office, this revelation has sparked widespread, national media attention.

The allegations giving rise to Commissioner Jones’ investigation into Aetna’s claims handling practices come from videotaped deposition testimony of Dr. Jay Ken Iinuma who served as medical director for Aetna’s Southern California business operations between March 2012 and February 2015. During the deposition, Dr. Iinuma said he was following Aetna’s training when he never once looked at patients’ medical records himself before denying their claims for coverage.

Dr. Iinuma’s deposition was taken as part of a lawsuit filed by a college student, Gillen Washington, who was denied coverage for an infusion of intravenous immunoglobin (IVIG) when he was 19 to treat a rare auto-immune disorder.  Washington sued Aetna in Orange County Superior Court for breach of contract and bad faith, alleging that Aetna’s “reckless withholding of benefits almost killed him.”  Aetna initially paid for Washington’s treatments (each fusion can cost up to $20,000) but when Washington asked Aetna to pre-authorize a November 2014 infusion, Aetna said it was obligated to review Washington’s medical records.  Aetna claims that Washington’s treating provider failed to timely provide medical records in response to Aetna’s pre-authorization review.  Washington counters Aetna’s narrative of the events surrounding Washington’s ongoing requests and medical need for IVIG treatment.  However, it was during Dr. Iinuma’s deposition, where the real bombshell in the case was revealed. The former Aetna medical director testified that he never read Washington’s medical records and knew nothing about the disorder Washington was suffering from despite denying Washington’s pre-authorization request and signing the denial letter.  Dr. Iinuma further testified that most of his work was done online and he would rarely if ever consult with an Aetna nurse about a particular claim prior to denying it.

In a story that’s far too common, Montreal writer Samuel Archibald recently shared his story of what he called “abandonment by his insurer.” While away from work on leave to treat his depression, Archibald was unknowingly tracked on social media by his insurance company – and everyday simple information about his life was used against him to deny his health claim. Out for a run? He must not be depressed. Eating a meal with family? He must not be depressed. Or at least these are the hasty judgments that his insurer made about his mental health. Did they take into account that exercise can be a wonderful natural anti-depressant? Did they take into account that eating is necessary to survive, and spending time with family can be a healthy part of treatment and recovery? Were they even medically trained to make this type of conclusion, and if so, is it ethical to make this type of conclusion without actually treating a patient in person? The questions go on and on, and in Archibald’s outrage, he took pen to paper and brought light to a very complicated issue in the insurance world. If their job is to help people when they are sick and in need, why are they so often leaving people hanging? Why are they causing harm?

Insurance companies have a bad reputation for paying health claims, and here’s why – they have a long history of denying claims and leaving people in the dark. Leaving people confused. Leaving people in financial distress. Leaving people to suffer without the support they are entitled to.

So what’s the reasoning behind all the denials? The insurer has a bottom line – and unfortunately the bottom line is not your health and wellness. “It’s an insurance company that administers the plan, that decides on the claim, and ultimately has to foot the bill if the benefit is granted – and that’s a conflict of interest that everyone can easily see,” said Sean M. Anderson, a University of Illinois expert in employee benefit plan policy and regulation.

          Often our clients are prescribed pain medication to help control the symptoms of their disabilities.  It is well recognized that the side effects of pain medication can be disabling. An employee should not be exercising judgment, operating machinery or driving while on pain medication. See, Sabatino v. Liberty Life Assurance Co. of Boston, 286 F. Supp. 2d 1222, 1231 (N.D. Cal. 2003) (insurance company’s reliance on medical opinion “suspect” where it failed to take account of claimant’s “severe and chronic pain and the cognitive impairments” caused by her pain medication); Godfrey v. BellSouth Telecomms., Inc., 89 F.3d 755, 759 (11th Cir. 1996) (decision to deny disability benefits arbitrary where insurer ignored side effect of drowsiness caused by claimant’s medication) and Adams v. Prudential Ins. Co. of America, 280 F. Supp. 2d 731,741 (N.D. Ohio 2003) (insurer’s decision to deny benefits arbitrary and capricious because the insurer ignored cognitive side effects of claimant’s medication).

          Insurers avoid the obvious disability caused by pain medications by utilizing an unfair review technique.  The insurer will employ a physician to review the medical records and the physician will report that “no adverse side effects of the medication were reported by the attending physician.”  This is a misnomer for two reasons: (1) If drowsiness or cognitive impairment is an expected side effect of the medication, it will not be reported as an “adverse” side effect and (2) the failure of one’s physician to record an expected side effect in the records does not mean that it does not exist.

          We recommend that you accurately report medication side effects to your physician.  You can also report that you do not drive while on the medication and whether you need to take a nap or rest as a result of drowsiness. You should ensure that your medical providers’ records are accurate to properly document your disability, including any and all effects of your medications.

At Kantor & Kantor, we see the same scenario over and over again.   An individual submits a claim to a life insurance company, seeking to receive the life insurance benefits due to them resulting from the death of a loved one.   However, instead of a check, the individual receives a letter from the insurance company telling them why they WON’T be receiving any benefits.     The beneficiary is shocked, but feels helpless.  

The insurance company must know what they are doing, RIGHT?   

The insurance company wouldn’t negligently or intentionally fail to pay which should be paid, RIGHT?

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