complex tort litigation | Managed Care Abuse
A voice for those denied medically necessary care.
Managed care abuse occurs when an insurance company delays or denies a patient’s medically necessary care despite the recommendation of a doctor or other health professional.
Managed care abuse occurs when an insurance company delays or denies a patient’s medically necessary care despite the recommendation of a doctor or other health professional. Delays and denials often happen because the adjuster reviewing a claim is not a trained medical professional and, worse, is sometimes incentivized to deny claims. Most importantly for the patient, a delay or denial can lead to aggravated health problems or additional injuries.
State and local government employees like firefighters, teachers, and police officers, the self-employed, and small business owners are the most vulnerable to managed care abuse because they do not have access to the same administrative remedies as people who are insured by group plans obtained through their private employers. Thus, they often must seek legal counsel and challenge their insurer’s delays and denials of medical care through the courts.
Chipps v. Humana Health Insurance Co. of Florida: After six years of litigation and a four-week jury trial examining Humana’s internal documents and abrupt termination of its managed care program for 100 catastrophically ill children in Florida in complete violation of its own policies and procedures, the jury awarded the Chipps family more than $1.03 million in compensatory and $78.5 million in punitive damages. 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.
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 […]