Health Insurance

November 24, 2017

What Do You Do If You Cannot Work Because of Mental Illness?

Mental health issues are definitely more widely spoken about in todays society. But lip service doesn’t necessarily help with the overwhelming challenges a person has to face in living with a mental illness.

Mental illness is more common than any of us would like. According to the National Institute of Mental Health there were an estimated 43.4 million adults aged 18 or older in the United States living with a mental illness in 2015. This number represented 17.9% of all U.S. adults. (See https://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-us-adults.shtml).

The National Alliance on Mental Illness reports the following statistics regarding mental illness rates in the United States:

November 20, 2017

What’s a “Church Plan” when evaluating your right to benefits under employer benefit plan?

by Kantor & Kantor LLP

As you know, churches occupy a special place in the law. For example, the First Amendment bars the government from prohibiting the free exercise of religion, and churches, indeed almost all religioous institutions, get special tax treatment from the IRS.

However, you may not know that this distinction can also affect your employee benefits. Almost all employee benefits are governed by a federal law called ERISA (the Employee Retirement Income Security Act of 1974). This law provides various protections, including imposing a fiduciary duty on your employer to act in your best interests in administering your benefits.

However, if you are a beneficiary of an employee benefit plan established by a church (or other religious organization), your benefits are not governed by ERISA, because ERISA has an exemption for “church plans.” (There is also an exemption for government plans.) As a result, you may lose protections under ERISA if you are a church employee.

August 28, 2017

What You Need To Know If Insurance Denies Coverage For Your Prescription Medication

by Kantor & Kantor LLP

Many people know that at Kantor & Kantor, LLP we help clients when their insurance company denies coverage life insurance claims, long-term disability claims, and eating disorder treatment claims. At Kantor & Kantor, LLP we also help clients when their insurance company denies claims for certain expensive medications including: curative Hepatitis C medications, ADHD medications and, Xyrem, a medication used successfully to treat a variety of disorders, including fibromyalgia and narcolepsy.

When Insurance Says Your Prescription Is “Not Medically Necessary”

Two women’s lives were inexplicably devastated after they attempted to fill their prescriptions for Xyrem, only to be told that their insurance company had denied coverage. One of the women, we’ll call her Jane to protect her anonymity, had been taking Xyrem for nearly a decade and the other woman, we’ll call her Mary, had been taking Xyrem for over five years. For both women, the medication had always been covered by their insurance companies. Yet for some unknown reason, when their doctors submitted their prescription-refill, both women received similar letters from their insurance companies (Cigna and Anthem) stating, “Coverage for the requested medication is denied because the medication does not meet the criteria of “medical necessity” under your description of benefits.” Both Cigna and Anthem also told the women that their prescription was “off-label” and therefore not covered for that reason, as well.

August 16, 2017

Why Appeal A Health Claims Denial… and How to Do It Right

by Kantor & Kantor LLP

Why should I appeal?

By appealing a claims denial, you are challenging the insurance company’s decision to deny benefits. Even if you think your appeal will not be approved, you should still appeal:

To get treatment records considered.

July 15, 2017

Whose “Clinical Judgment” Applies to Insurance Denials?

by Kantor & Kantor LLP

The classic “he said, she said” scenario shouldn’t apply to healthcare claims. A denial based on medical necessity arises when there are two opposing opinions: (1) the treating physician who recommends that a patient receive treatment necessary for the patient’s condition; and (2) the insurance company’s physician reviewer who has never seen the patient. In deciding medical necessity, the insurance company must consider clinical judgment. But whose clinical judgment applies?

Clinical judgment is defined as “the application of information based on actual observation of a patient combined with subjective and objective data that lead to a conclusion.” http://medical-dictionary.thefreedictionary.com/clinical+judgment. In most cases, the only physician who has “actual observation of a patient” is the treating physician.

Yet insurance companies give little to no credence to the clinical judgment of treating physicians. For example, major health insurer, Anthem, states that its physician reviewers will apply guidelines, “Anthem corporate medical policy, and other decision-support material.” And when criteria is not available, “physician reviewers make a determination based on the available information and their independent clinical judgment.” https://www.anthem.com/wps/portal/ahpfooter?content_path=provider/nv/f4/s4/t0/pw_002053.htm&label=Medical%20Management

July 10, 2017

Make sure you share all your symptoms with your doctors!

by Kantor & Kantor LLP

With increasing frequency, insurance companies like Cigna, Unum, MetLife and Prudential are denying long-term disability (“LTD”) claims due to discrepancies between what the claimant/treating physician is saying on the claim forms and what is stated in the medical records. Essentially, the insurance company will say that the symptoms being described for purposes of the LTD claim are not reflected in the treatment records, so there’s no proof that these were ongoing problems.

This often occurs because of one main reason: people always want to put their best foot forward. When the doctor starts the appointment with “how are you feeling?” it’s in our human nature to simply reply “I’m doing okay.” Generally, no matter how we’re actually feeling, we don’t want to be viewed as a complainer so we may tend to downplay our symptoms, even to the extent of telling our doctor that everything is fine…when it’s clearly not. Usually, when we respond this way, we mean that everything is okay considering the circumstances we find ourselves in, or sometimes just that “things could be worse.” But, that’s not how it later appears in medical records. Instead, what this often leads to is medical records showing “no active complaints” or “patient is improving” or “symptoms have subsided,” which gives the insurance company all the ammunition they need to deny the LTD claim.

So, be clear with your doctors about everything you’re experiencing. Don’t hide your symptoms. Be detailed, and offer real-life examples. Don’t just say “I’m having memory problems.” Give examples of having lost something, or forgot something you’ve never before forgotten. Instead of “I’ve been very fatigued lately” explain what you were doing (like shopping, or picking up a child, or gardening, etc.) and how your fatigue interupted or prevented you from finishing the activity. Also, check with your doctor or the doctor’s staff, to make sure everything you’re telling him/her is making it into your records.

June 28, 2017

Kantor & Kantor Prevails on an Eating Disorder Case in the State of New Jersey

by Kantor & Kantor LLP

Kantor & Kantor is happy to announce that it has won an important victory in New Jersey on behalf of a client with bulimia nervosa. The decision touches upon issues that we see too often in health insurance denials and long-term disability denials.

Our client, whose name is being kept anonymous to protect her privacy, began experiencing symptoms of her eating disorder when she was only eight years old. The eating disorder was left untreated for ten years. When she entered a residential treatment facility for her bulimia in September 2011, the facility submitted a claim for benefits to her insurance company, Horizon Blue Cross Blue Shield of New Jersey.

In a series of concurrent reviews, Horizon and its behavioral health managed care partner, Magellan Behavioral Health, paid for the first three weeks of treatment, but refused to pay past that date, contending that the treatment she was receiving was no longer “medically necessary.”

June 16, 2017

Tips for Talking to a Lawyer

by Kantor & Kantor LLP

There may come a time in your life when you will need to consult with a lawyer – whether it be good news or bad news. We routinely speak with individuals who have had life, health, and disability claims denied by their insurance companies. Understandably, this is a very difficult time for the individuals who call us. We understand that, and try to make the process simple…but we need your help.

As lawyers, we are well-versed in the practice of law, but we rely on the information from our clients to steer us in the right direction and guide each case. It takes TEAMWORK to get a successful outcome for our clients.

Here are a few tips for talking to your lawyer and sharing with them what they need to know.

May 12, 2017

Just Because An Insurance Company Denies Your Life, Disability or Health Insurance Claim, DOES NOT MEAN YOU SHOULD GIVE UP!

by Kantor & Kantor LLP

For over 25 years, I have been representing individuals who have had life, health, and disability claims denied by their insurance companies. I have represented over 3,000 people. What is so disheartening to me is that I hear from clients again and again that they “almost gave up before calling” me. They tell me they were beaten down by the process, convinced their insurance company must be right, or that they didn’t know there were lawyers who specialized in handling their kind of case on a contingent basis. While sometimes the client HAS waited too long for us to help them, usually my law firm, Kantor & Kantor, is able to step in and successfully resolve their claim.

However, I wonder just how many DO give up unnecessarily. While my view of the insurance industry may appear very cynical, I am 100% convinced that the industry employs a strategy of denying as many claims as possible in the hope that claimants will just give up and go away. I could write pages upon pages of stories about clients who had almost given up, but for whom we were able to obtain benefits with nothing more than a well written letter. It sometimes seems like the insurance company is daring their insured to challenge the denial, or to get a lawyer. If they do, the insurance company will reconsider its denial. If not, the denial will stand and the insurance company will keep the benefits which are rightfully yours.

In the last month, I have obtained over a $1,000,000 in total benefits for several clients who separately told me that they had seriously considered giving up before calling my firm. This led to me to come back to a familiar thought, which was to wonder about all the people who did simply give up. I decided to write this blog in the hope that maybe ONE insured might read it, and decide not to give up. I am not writing this to get business. I have more than I need. I practice in California, but this blog might be read by someone in Florida, or Illinois, or New Jersey, for example. If it is, and you were considering giving up trying to get your benefits, I am not suggesting you call me. Go on the internet, or call your State Bar, and find an experienced attorney in your State. The worst thing that happens, is that no one will take your case — but what if they will?

April 7, 2017

In-Network versus Out-of-Network: What you need to know when selecting a medical provider

by Kantor & Kantor LLP

One of the first questions we ask clients calling about the denial of medical benefits is whether the provider (i.e. hospital, treatment center, doctor) was an in-network or out-of-network provider. Some insurers use different terms such as participating provider or contracted provider. These terms all mean that the insurance company, or its claims administrator, has negotiated with the provider for a certain rate of reimbursement. Insurance companies negotiate these rates of reimbursement with certain providers so that there is an expectation – from both the insurance company and the provider – of the amount that will be paid for medical services.

For patients who are seeking benefits for medical services, a provider’s network status is important because it affects how much the patient will pay out of pocket for treatment. When patients use an out-of-network provider, there is an additional coinsurance, or charge, that patients must pay out of pocket. This coinsurance can range from 20% to 50% of the eligible charges. Eligible charges are a lesser amount determined by any number of factors in the insurance policy, such as Medicare rates. So when patients receive bills from the provider, or statements from the insurance company, which show that only a fraction of the out-of-network provider’s charges were paid, the reason is that the eligible charge was determined to be less than the billed charges and a coinsurance applied. This can dramatically reduce what the insurance company will pay for an out-of-network claim.

Here are some tips for reducing out-of-pocket medical expenses: