Mehri & Skalet represents people in disputes with insurance companies, including people whose claims insurance companies have refused to pay or who have been overcharged, unfairly discriminated against, or unlawfully declined or misled. We also represent and advise governmental entities, non-profit organizations and interest groups regarding insurance-related issues.
With the passage in March 2010 of the Affordable Care Act– also known as Obamacare –the federal government for the first time has established minimum standards that health insurers in all states must follow. Some insurers, providers and government officials have embraced these changes – but others have not. And due to budget constraints and other factors, the states and the federal government can obtain relief for only a tiny fraction of all the people involved in disputes with insurance companies.
When insurers violate the law, therefore, private litigation may well be necessary. Combining M&S partner Jay Angoff’s unique expertise as both a state and federal insurance regulator with Mehri & Skalet’s experience in holding major corporations accountable, the firm is well-prepared to do battle with insurers. Among the types of cases in Mehri & Skalet is interested in pursuing:
Failure to pay claims. Some insurers routinely refuse to pay for certain claims by policyholders or medical providers when they’re first submitted, reasoning that a certain percentage of claimants will give up and not pursue their claim. In addition, some insurers sell very limited coverage but convey the impression that their policies cover more than they really do, and then fail to pay claims the insured reasonably believes are covered.
Excessive or unjustified rates. Many states have laws prohibiting insurers from implementing excessive or unjustified rate increases, or charging people more based on certain prohibited factors such as race and, in many states, other factors such as credit history, occupation, education or length of prior coverage.
Violations of the Affordable Care Act
Conduct prohibited by the ACA since its enactment in 2011. Insurers must allow young adults to stay on their parents’ policies until they’re 26; can’t refuse to insure kids under 19 with pre-existing conditions; can’t cancel coverage after a policyholder has filed a claim; can’t cut off a policyholder’s coverage once he or she reaches a certain monetary limit; and can’t require their insureds to pay deductibles, co-payments or co-insurance when they obtain preventive services from in-network providers, or when they receive emergency treatment from out-of-network providers. In addition, insurers may not impose dollar limits on any Essential Health Benefit as defined by the ACA.
Conduct prohibited beginning in 2014. Effective January 1, 2014, health insurers are prohibited from declining people for coverage or from surcharging people based on health status, and are also prohibited from charging the oldest people they insure more than three times what they charge their youngest insureds. They are also prohibited from marketing their policies in a discriminatory manner. People who do not get insurance at work have the right to buy insurance of four standard values, and to obtain subsidies if they earn less than $46,680 (for an individual) or $95,400 (for a family of four). Mehri & Skalet is interested in hearing about any non-compliance with the new ACA rules.
Fraud against the government by insurers, hospitals, doctors, nursing homes, drug companies, medical device makers and others
In 2012 the two largest government insurance programs, Medicare and Medicaid, cost taxpayers a total of $833 billion– more than $100 billion of which is fraudulent, according to most estimates. Under the federal whistleblower law, people who blow the whistle on fraud against the government by filing a lawsuit can be eligible for a reward of up to 30% of the amount recovered.
Actions by state or federal governmental entities that violate federal law. The federal agencies implementing the Affordable Care Act have on occasion taken actions that conflict with the language of the Affordable Care Act and the regulations the agencies themselves have promulgated to implement it. For example, an HHS regulation requires HHS to make public the information insurers file with HHS to justify their proposed increases so that consumers can comment on them and HHS can consider those comments in determining whether the proposed increases are reasonable. In fact, however, HHS has not disclosed information regarding proposed rate increases, thus defeating the purpose of its own regulation. Although challenging unauthorized actions by government officials is fraught with difficulties, Mehri & Skalet is interested in discussing such potential challenges with those injured by such actions.
Redlining refers to the practice of refusing to sell insurance in certain areas–in effect, drawing a red line around that area–or to certain populations. While this practice is less prevalent than it once was, it has not disappeared. For example, On July 7, 2004, Mehri & Skalet, along with co-counsel, initiated a groundbreaking class action lawsuit against John Hancock Life Insurance for its company-wide policy of rarely selling life insurance to African-Americans in the early to mid-20th century. In August 2009, the U.S. District Court for the District of Connecticut granted final approval of a $24.4 million race discrimination class action settlement with John Hancock Life Insurance Company, resolving claims of decades-old discriminatory practices in the sale and marketing of life insurance policies to African-Americans. Read more about the case here.
Representing and advising state insurance departments, consumer coalitions, and other interest groups. During the late 1990s and early 2000s, non-profit Blue Cross companies frequently sought to convert to for-profit status and/or be acquired by larger Blue Cross companies, and large for-profit insurers merged with other for-profit insurers. With the enactment of health reform and the incentives it creates for insurers to reduce their costs, more acquisitions, involving both non-profit Blue Cross carriers and for-profit carriers, are likely to occur. Mehri & Skalet partner Jay Angoff advised the Montana Insurance Department regarding the proposed acquisition of the Montana Blue Cross plan by Health Care Service Corporation. The transaction was approved on June 27, 2013, after HCSC agreed to more than double its original offer,which will fund a health-care foundation,and to keep its administrative costs below those of what the independent Montana plan’s had been.
Mr. Angoff has also advised the Pennsylvania and Maryland Insurance Departments in connection with their review of proposed acquisitions of Blue Cross plans, and as Missouri Insurance Commissioner ordered Blue Cross of Missouri to establish what is now one of the nation’s largest healthcare foundations with the full value of its assets when it converted to for-profit status. In addition, Mr. Angoff advises consumer coalitions and other interest groups on health-, auto-, and medical malpractice-related issues.
If you believe that you have suffered losses due to fraudulent activity, please contact us regarding your potential claims.