Managed Care Abuse

Managed care abuse litigation is highly complex, involving an often-complicit system in which insurance carriers delay or deny a patient’s medically necessary care, despite recommendations by doctors or other health professionals, leading to exacerbated or additional injuries. This can include workers’ compensation carriers, health maintenance organizations (HMOs), and other managed care providers and third-party administrators, who are often motivated by cost-cutting incentives.

Cohen Milstein is at the forefront of managed care abuse litigation.  Our attorneys, successfully tried Chipps v. Humana (Cir. Crt., Palm Beach Cnty., Fla.), forever altering how insurance carriers process and authorize medically necessary claims. The American Association for Justice, the nation’s preeminent plaintiffs’ trial association, lists Chipps v. Humana as one of the most influential lawsuits to mitigate corruption in the healthcare industry.  The litigation involved the denial of care for a severely disabled child with cerebral palsy by Humana Health Insurance Company of Florida, one of the country’s largest healthcare providers.

We have extensive, successful litigation experience in this challenging area of law, having represented clients against Humana, Bridgefield Casualty Insurance Company, The Claims Center, Genex Services, Inc., Heritage Summit Healthcare, Travelers Indemnity, Guarantee Insurance Company, Sunz Insurance Company, United Healthcare, and others.

If you or a loved one has been injured and you believe you may have a legal claim, please contact us at (877) 515-7955 or fill out our free case evaluation form.

Our Services

We litigate cases against traditional managed care and health insurance companies, as well as cases against workers’ compensation insurance carriers, that intentionally interfere in the provision of medical care and treatment to injured workers.

• Managed Care Provider Abuse: Managed care and health insurance companies, including HMOs, often deny or delay crucial medical care solely to reduce cost and increase profit.  Such companies often deny care that they decide is not medically necessary, despite the care being ordered by the patient’s health care provider.  To the extent patients suffer from being denied medical care (including emotional suffering), they may have a valid legal claim against the managed care company.
• Workers Compensation Abuse: When the patient is an injured worker whose medical care or treatment is wrongfully denied or delayed by her employer or the workers’ compensation carrier, the law often requires that the employer or carrier must have caused the denial or delay through an intentional course of conduct in order to be subject to civil liability.  Satisfaction of this standard can be difficult and deters many law firms from bringing civil actions for the wrongful denial of treatment to an injured worker.  We, however, have had great success in this area of law and welcome the opportunity to assist injured workers obtain just compensation after being intentionally deprived of timely medical care and treatment needed as a result of suffering a workplace injury.

Our Team

Theodore J. Leopold, who leads the firm’s Managed Care Abuse team and co-chair’s the Complex Tort Litigation practice, was the lead trial attorney in Chipps v. Humana and was nominated by the Public Justice Foundation as “Trial Lawyer of the Year” for his leadership in this ground-breaking litigation against the managed care industry, which was also featured in the National Law Journal’s “Top Verdicts of the Year.” Mr. Leopold is also frequently recognized by peers as being among the best in his area of practice. He was named to Lawdragon’s “500 Leading Lawyers in America” (2020, 2021), The Legal 500's “Leading Lawyers” (2021), “Best Lawyer” by 28th Edition of The Best Lawyers in America (2022) and “Top Lawyer” by Palm Beach Illustrated 2021, “Distinguished Leader” by Daily Business Review (2021), Florida Super Lawyer (2021).

Leslie M. Kroeger, a highly accomplished trial attorney and co-chair of the Complex Tort Litigation practice, actively litigates managed care abuse cases and speaks frequently on managed care legal trends, including at the Florida Workers’ Advocates Annual Conference and the North Carolina Advocates for Justice Annual Conference. Ms. Kroeger is recognized for her leadership and legal skills. She was named Lawdragon’s “500 Leading Lawyers in America” (2020, 2021), “Best Lawyer” by 28th Edition of The Best Lawyers in America (2022), “Top Lawyer” by Palm Beach Illustrated (2021), Florida Super Lawyer (2021), and recognized in the 2021 edition of Florida Trend’s “Florida Legal Elite”. Sher is the past-president of the Florida Justice Association.

Diana L. Martin, an appellate attorney, focuses extensively on managed care abuse litigation. Given the complexity of managed care abuse litigation, her appellate experience is integral to the overarching litigation strategy, developing novel legal theories, arguing complex issues of law, and assisting trial counsel in preserving and protecting the record in the event of an appeal. She was recognized by her peers as a “Best Lawyer” by 28th Edition of The Best Lawyers in America (2022) and “Top Lawyer” by Palm Beach Illustrated (2021). 

As a result of our decades of litigation experience in the managed care industry, we are familiar with industry trends nationwide and have an extensive network of industry experts and other specialized service providers who are able to assist in addressing myriad investigation, fact-pattern, and discovery requirements.

Our Approach

We are compassionate to patients who have fallen victim to a managed care company’s refusal to pay for necessary or life-saving treatments. As more victims come forward and pursue litigation, we are able to force these companies to unveil their byzantine and many times complicit business practices, and often, through court order or successful litigation, force them to change their unethical practices. Through the court system we can help clients receive just compensation and effect regulation of the managed care industry in order to prioritize and better manage the health and welfare of patients.

Representative Matters – Denial of Care & Delayed Care

• Chipps v. Humana Health Insurance Co. of Florida: After six years of litigation and a four-week jury trial, the jury awarded the Chipps family more than $1.03 million in compensatory damages and $78.5 million in punitive damages.  The trial examined Humana’s internal documents and its abrupt termination of its managed care program for 100 catastrophically ill children in Florida; a termination that was in complete violation of its own policies and procedures. This landmark lawsuit uncovered widespread fraud at Humana, including the payment of bonuses to physicians and nurses based on the number of medical claims they denied each month.  The American Association for Justice lists Chipps v. Humana as the top “Cases That Made a Difference” for healthcare.
• Jane Doe v. Humana: After Humana wrongfully raised the co-pay on his leukemia medication from $40 per month to more than $700 per month (25% of the cost of the medicine), John Doe was unable to afford the medication and as a result died of the cancer.  On behalf of the Plaintiff, we sued Humana for John Doe’s wrongful death on the grounds of negligence, negligent or fraudulent misrepresentation, breach of contract, and breach of fiduciary duty.  We successfully settled this case prior to trial.
• Gillig v. United Healthcare: Philip Gillig’s family and doctors spent over a two-month period attempting to gain HMO authorization for specialized care, antibiotic treatment, surgery, and hospitalization.  Their attempts failed due to United Healthcare employees’ refusal to return calls and their misconduct in sending calls to a voicemail system at United Healthcare that they knew was “full” and could not accept messages.  As a result, Mr. Gillig fell into septic shock and suffered significantly. United Healthcare failed to provide Mr. Gillig with timely access to medical care and treatment, thereby failing to administer medically necessary benefits, despite Phillip Gillig’s declining condition.  On behalf of Mr. Gillig and his wife, we brought a civil action for negligence, breach of fiduciary duty, and breach of contract.  We successfully settled this case prior to trial. 

Representative Matters – Denial of Workers’ Compensation Benefits

• Jane Doe v. Travelers Indemnity Company: The Plaintiff suffered a workplace injury, involving her back, which required medical treatment.  The workers’ compensation insurance carrier assigned a medical case manager and retained a medical case management service provider to monitor Plaintiff’s case.  The carrier and its agents ignored multiple physician recommendations for prompt, medically necessary surgery, under the purported belief that the injury was not work-related.  After failing to provide this medically necessary care for a 10-month period, Plaintiff’s condition deteriorated to the point that she was permanently disabled and could no longer benefit from the surgery.  On behalf of the Plaintiff, we sued the carrier and its agents for intentionally breaching their fiduciary duty by preventing her from receiving timely and appropriate medical care, and subjecting her to intentional infliction of emotional distress. We successfully settled the case after Defendant’s motion to dismiss was denied.

• John Doe v. A Workers’ Compensation Insurance Company: Our Plaintiff was an undocumented worker from Central America.  At the specific request of his employer, he assumed a false social security number and new identity.  While on the job, he suffered an injury which rendered him a quadriplegic.  The workers’ compensation carrier denied Plaintiff’s workers’ compensation claim under the contention that he had committed insurance fraud.  This was despite the employer’s involvement in the Plaintiff’s use of false information during his employment.  On behalf of the Plaintiff, we sued the carrier and employer for intentionally breaching their fiduciary duty by preventing him from receiving timely and appropriate medical care, and subjecting him to the intentional infliction of emotional distress.  We successfully settled the case prior to trial.

• Parodi v. The Claims Center & Bridgefield Casualty Insurance:  Plaintiff suffered a workplace injury, which necessitated rotator cuff surgery. The surgery provided temporary relief, but Plaintiff’s pain returned and doctors authorized by the workers’ compensation carrier diagnosed Plaintiff with Reflex Sympathetic Disorder (RSD), a chronic regional pain syndrome. The doctors determined Plaintiff required aggressive treatment from a RSD specialist. The workers’ compensation carrier and its agent third-party administrator claimed they did not have such a specialist in their managed care network, and refused to send Plaintiff outside the network for treatment. Defendants also persisted in restricting Plaintiff’s access to RSD treatment after the Judge of Compensation Claims ordered them to authorize a specialist to provide a specific RSD treatment protocol. On behalf of the Plaintiff, we sued the workers’ compensation carrier and its administrator for intentional infliction of emotional distress and intentional breach of fiduciary duty. We successfully settled the lawsuit after defeating Defendants’ motion for summary judgment and obtaining leave of court to seek punitive damages.

• John Doe v. Sunz Insurance Company and CorVel Corporation: John Doe suffered a workplace injury, which caused numbness in his legs and down one arm. The orthopedic surgeon authorized by the workers’ compensation carrier and its third-party administrator determined Plaintiff suffered a serious cervical injury in the workplace accident and requested authorization to perform emergency surgery. Despite having no medical information or opinion contrary to that given by the doctor they authorized, Defendants denied the request for surgery, finding it was not related to the workplace accident. When Plaintiff sought an emergency hearing before the Judge of Compensation Claims, Defendants retaliated by completely terminating Plaintiff’s workers’ compensation benefits, including indemnity benefits, despite knowing this would make Plaintiff destitute. Plaintiff’s condition deteriorated to the point that his doctor performed the surgery on an emergency basis without knowing whether he would ever receive compensation for his efforts. Nevertheless, Plaintiff suffered permanent injuries as a result of the delay in receiving the surgery. On behalf of the Plaintiff, we brought a civil action for intentional infliction of emotional distress and intentional breach of fiduciary duty, which was removed to arbitration due to an arbitration clause in the contract between the workers’ compensation insurer and third-party administrator. We successfully settled the lawsuit prior to arbitration.

Fill out our free case evaluation form, if you believe you have a legal claim.