Insurance and Healthcare Litigation and Consulting

M&S 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. The combined expertise of our Insurance & Healthcare and Whistleblower practice teams provides whistleblowers and healthcare fraud tipsters with the strategic insights necessary to investigate and litigate their claims. We also represent and advise governmental entities, non-profit organizations and interest groups regarding insurance-related issues.

Protecting Consumers through Litigation

Combining M&S partner Jay Angoff’s unique expertise as both a state and federal insurance regulator with M&S’s experience in holding major corporations accountable, the firm is well-prepared to do battle with insurers and other entities in the health care system. Among the types of cases in Mehri & Skalet is interested in pursuing:

Enforcing the Affordable Care Act. 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. For example: Insurers must allow young adults to stay on their parents’ policies until they’re 26.

  • Insurers can’t cancel coverage after a policyholder has filed a claim.
  • Insurers can’t cut off a policyholder’s coverage once he or she reaches a certain monetary limit.
  • Insurers 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.
  • Insurers must cover certain “Essential Health Benefits” and can’t impose dollar limits on these benefits.
  • Insurers can’t decline people for coverage or surcharge people based on health status or gender.
  • Insurers can’t charge the oldest people they insure more than three times what they charge their youngest insureds.
  • Insurers can’t market their policies in a discriminatory manner.
  • Insurers must spend at least 80% of premium dollars on health care claims and quality improvement activities or pay policyholders a rebate.
  • Insurers must cover mental health and substance abuse services on a comparable level to physical health care services.
  • Insurers can’t discriminate against applicants or policyholders on the basis of race, color, national origin, sex, age, or disability.

Despite repeated attempts to repeal the law, these protections remain in place today. 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. Additionally, state and federal entities charged with implementing and enforcing the law 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. 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.

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.

Fraud by insurers, hospitals, doctors, nursing homes, drug companies, medical device makers and others. In 2016 Medicare spent $672.1 billion on health care– $76.2 billion of which is fraudulent, according to recent 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.

Private individuals and payors may also seek recovery for fraudulent pay outs. For example, Mehri & Skalet represents both public and private entities seeking to recover costs spent on unnecessary and inappropriate opioid prescriptions that contributed to the national opiate epidemic.

Redlining. 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.

Contact Us

If you believe that you have suffered losses due to fraudulent or unlawful activity, please contact our attorneys regarding your potential claims.