A recent CNN report ("Insurer skips doctors and sends massive checks to patients, prompting million-dollar lawsuit" March 1, 2019 - https://www.cnn.com/2019/03/01/health/anthem-insurance-payments-patients-eprise/index.html) highlights a serious problem faced by medical providers such as mental health rehabilitation facilities in obtaining payment for the services they provide. Health insurers typically allow patients to assign payment for the services they receive in order to permit providers to receive prompt direct payment for their services. This is a unique feature of healthcare in America since this issue does not arise in countries that have single-payer healthcare since there is no need to rely on patients to pay providers for the services they receive.
Individuals who suffer from eating disorders often run into difficulties securing coverage from their health insurers for treatment, especially for residential care. Last year, ERISA lawyer Mark DeBofsky of DeBofsky Sherman Casciari Reynolds P.C. contacted Illinois State Representative Laura Fine and Illinois State Senator Julie Morrison with an idea to amend the Illinois Insurance Code to provide health insurance coverage for eating disorders in line with the mental health parity law. That idea ultimately became HB 1332, introduced in the Illinois House of Representatives by Representative Fine and in the Illinois Senate by Senator Morrison. Both houses of the Illinois General Assembly recently passed HB 1332 and it awaits signature by Illinois Governor Bruce Rauner in order to become law.
By William Reynolds
One of the most important aspects of the Affordable Care Act, or Obamacare as it is commonly known, is the right to seek independent review of a health benefit denial. The notion of an independent review of an insurance company's decision may seem to be a fair and objective way to resolve a dispute over coverage, but it is not always the panacea it seems.
DeBofsky, Sherman & Casciari recently won the case of Warner v. Unum Life Ins. Co., No. 12 C 02782, 2014 U.S. Dist. LEXIS 178765 (N.D. Ill. Dec. 31, 2014), where the district court granted summary judgment for the plaintiff, ruling that Unum Life Insurance Company ("Unum") acted arbitrarily and capriciously by disregarding the results of a functional capacity evaluation the plaintiff underwent that found her incapable of performing her former occupation as a nurse due to fibromyalgia, chronic back pain, and other impairments.
Quis custodiet ipsos custodes?