Articles Tagged with Kantor & Kantor

Two decisions this week emphasize the importance of submitting treating physician and patient statements in support of an ERISA administrative appeal. For ERISA health cases involving medical necessity denials, an appeal which gets to the heart of why treatment was medically necessary is crucial and can actually determine the course of the lawsuit.

In Katherine P. v. Humana Health Plan, Inc., No. 19-50276, __F.3d__, 2020 WL 2479687 (5th Cir. May 14, 2020), the Fifth Circuit revived life into a claim by a young woman seeking mental health benefits for partial hospitalization treatment. Katherine received partial hospitalization treatment in 2012 for multiple mental health disorders including an eating disorder. Humana paid for the first 12 days of partial hospitalization treatment and then denied benefits, claiming such treatment was no longer medically necessary based on two Mihalik Criteria.

The Fifth Circuit found that judgment for Humana was improper because the administrative record showed a genuine dispute as to whether Katherine satisfied one of the Mihalik Criteria, ED.PM.4.2.

For Immediate Release

May 7, 2020

Kantor & Kantor, LLP and Dawson & Rosenthal, P.C. FILED A COMPLAINT in the United States District Court, Central District of California on behalf of their client Sovereign Health, a Gold Star Award winning healthcare provider that treated mental health, substance abuse, and dual diagnosis patients . The $1.125 billon suit alleges that Health Net, Centene Corporation, attorneys from Manatt, Phelps & Phillips, and others engaged in practices that are in violation of the Racketeer Influenced and Corrupt Organizations Act (RICO); Conspiracy to Violate RICO; Intentional Interference with Prospective Economic Advantage, Violation of Unfair Competition Law; and Slander.

Fire season is beginning again in California, and soon throughout the West. Thousands of people are still trying to recover and rebuild from the years of past fires and related devastation. It is often taking three or more years to rebuild a home because of difficulties obtaining permits, contractors, and materials.

Ideally, your insurance company will work with you in this difficult time in your life. You will need to obtain a copy of your insurance policy and review it carefully. This can be harder than it seems if you have just lost all your possessions in a fire, as you may not even have access to a computer for some time. It is important to understand that the amount the insurance company set to insure your house may be much less than it would cost to rebuild your house. The insurance company will also only pay to rebuild your house as it was before, it will not pay for upgrades.

You will be asked to provide lists of the contents of your home. Then the insurance company will likely only reimburse you for the “actual cash value” of the possessions you lost in the destruction of your home, which removes depreciation from the value of your items. If your policy covers it, once you actually replace the item, you may receive a second payment covering that depreciation. But if you do not replace the item, you never will.

The Lupus Foundation of America estimates that 1.5 million Americans, and at least five million people worldwide, have a form of lupus. According to the Lupus Foundation of America most lupus sufferers are misdiagnosed or can go undiagnosed for years. The goal of Lupus Awareness Month is to inform practitioners, patients, care givers, and the general public about how best to diagnose, care for, and live with lupus.

What is Lupus?

Lupus is a chronic (long-term) disease that can cause inflammation and pain in any part of your body. Lupus is a non-contagious autoimmune disease, which means that your immune system — the body system that usually fights infections — attacks healthy tissue instead. According to the Centers for Disease Control and Prevention about 9 out of 10 diagnoses of lupus are in women ages 15 to 44 and most people with lupus develop the disease between the ages of 15-44.

Even though most of us are still sheltering in place in an attempt to lessen the immediate spread and most severe health consequences of COVID-19, it is not too soon to start considering possible long-term health impacts that may arise in the wake of the coronavirus pandemic.

Because the virus affects many organs and systems within the body – from the lungs and cardiovascular system to the liver, kidneys and likely the brain – it now appears likely that at least some patients will suffer long-term physical symptoms.  These long-term and even permanent problems may result from the virus itself, the body’s own immune response or even medical interventions, especially respirators, or a combination of all these factors.  But whatever the cause, doctors are already seeing heart damage, kidney and liver damage and, unsurprisingly, lung scarring and damage in a number of COVID-19 patients who are no longer actively infected.

And these are still early days. Some patients present during the illness with serious neurologic problems such as strokes and encephalitis, as well as other more mild neurologic symptoms such as dizziness, headache and loss of smell.  There have been reports of some patients suffering from Guillain-Barré Syndrome, an auto-immune disease where the immune system responds to an infection by mistakenly attacking the body’s own nerve cells.  It seems possible that at least some of these patients may continue to suffer neurologic and autoimmune issues, and related pain, fatigue and cognitive difficulties for at least some time.

Millions of people are affected by mental illness each year. While 1 in 5 people will experience a mental illness during their lifetime, everyone faces challenges in life that can impact their mental health. As the increase in the number of COVID-19 cases affects our entire country, so too will the need for access to mental health treatment and awareness of mental health issues. So far, older adults, along with those who have underlying health conditions, have been hit the hardest by the COVID-19 outbreak, with many developing severe, life threatening illnesses. Another group that is expected to be acutely affected by the pandemic include those who have severe mental illness.

Mental illness is a real and treatable set of conditions that includes major depression, bipolar disorder, eating disorders, panic attacks, generalized anxiety disorder, attention deficit hyperactivity disorder, and schizophrenia, among dozens of others. These disorders are serious enough to significantly impact a person’s daily life functioning, whether at school, work or in their relationships with others.

Mental health issues often coincide with a unique set of challenges that make it difficult for people to access even the most necessities, such as food, medications, stable housing, and healthcare. Combined, all these factors put people with severe mental illness at a much higher risk for contracting and transmitting the new coronavirus and dealing with COVID-19.

As we might expect during this time of pandemic, state governments are not able to make progress on many pressing issues. In January, California governor Gavin Newsom unveiled a $47 billion proposal to expand health care coverage to all Californians. However, the coronavirus scourge has sidelined that proposal as California has scrambled to find funds to respond to it.

Due to these funding pressures, Governor Newsom has asked lawmakers to prioritize their legislative agendas and focus on the outbreak. One senator, however, is pushing ahead with a proposal to protect Californians suffering from mental illness.

As reported by Kaiser Health News, California State Senator Jim Beall, who is the chair of the Senate Select Committee on Mental Health, wants to toughen state parity laws to ensure that patients with mental illnesses are provided benefits on par with those received by patients with other medical conditions. California and the federal government already have mental health parity laws on the books, but Senator Beall argues that they are not stringent enough and are poorly enforced.

On April 28, 2020, the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) issued deadline relief and other guidance under Title I of the Employee Retirement Income Security Act of 1974 (ERISA) to help, among other groups, disability plan participants who are impacted by the COVID-19 pandemic, also referred to as the coronavirus outbreak.

The Department of Labor, Department of the Treasury, and the Internal Revenue Service issued a joint notice explaining the extension of time frames for healthcare coverage, portability, and continuation of group health plan coverage under COBRA, and time frames to file a benefit claim or appeal of denied claims.  They also issued COVID-19 FAQs for Participants and Beneficiaries that address a number of common questions concerning health and retirement benefits.

The final rule published by EBSA and submitted to the Office of the Federal Register (OFR) for publication contains information of the extension of certain timeframes under ERISA and the Internal Revenue Code for group health plans, disability and other welfare plans, pension plans, and participants and beneficiaries of these plans during the COVID-19 National Emergency.

The COVID-19 pandemic has uprooted the lives of millions of Americans in many ways and has taken its toll physically and mentally on millions of Americans across the country. But for people who suffer from mental health issues, the COVID-19 pandemic has created a new wave of panic, chaos, stress, and uncertainty.

More than 2 million Americans are estimated to be affected by obsessive compulsive disorder (“OCD”), according to the Anxiety and Depression Association of America. Nearly 7 million people in the U.S. are affected by generalized anxiety disorder and about 6 million people in the U.S. are affected by panic disorder. Fear and anxiety about COVID-19 can be overwhelming and cause stress in both adults and children.

Stress during COVID-19 might include:

The effect of COVID-19 on the lives of every American cannot be overstated.  What we cannot know yet is how those effects will continue into the future.  We buy insurance to protect us in the event of future calamities. A variety of different types of insurance could potentially be triggered by the varying effects of the disease.  As it can be hard to know what the future could hold, the points below summarize the different ways your insurance could be involved in COVID-19 repercussions in the months and even years ahead.

It is difficult to know with certainty the range of long term health issues that could be caused by COVID-19, as the virus has only plagued us for approximately six months. Doctors predict the long-term effects will be similar to other coronaviruses like SARS.  While 80% of sick patients had “mild” cases, of the 20% who did not, they could experience a variety of long term effects.  COVID-19 survivors are expected  to follow the path of severe respiratory issues often seen after recovery from other respiratory illnesses.  That could mean lung fibrosis, reduced lung capacity and difficulty breathing and fatigue. Preliminary data out of China demonstrates that 20% of patients hospitalized with COVID-19 had heart damage. Patients also experience increased blood clotting.  Early studies from Asia show that COVID-19 attacks T-cells in a manner similar to HIV. Doctors are also finding that close to half of those hospitalized for COVID-19 have blood or protein in their urine, which is an early indicator of kidney damage, and up to 30% of patients in New York and Wuhan lost some level of kidney function. Liver damage, intestinal damage, and neurological malfunctions have also been reported.

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