April 14, 2020
Some insurance carriers delay or deny a patient’s medically necessary care, despite recommendations by doctors or other health professionals, in order to reduce costs and increase profits.
A delay or denial can happen to anyone with a health care plan. However, firefighters are particularly vulnerable because, as government employees, their plans are not protected by the Employee Retirement Income Security Act of 1974 (ERISA) in the United States.
Protections For Firefighters
Without the protections of ERISA, insurance carriers can more easily get away with delaying or denying claims without significant pushback – which can ultimately harm the patient and lead to exacerbated injuries. However, some states, such as Florida, have protections in place so that firefighters and other similarly situated workers can seek legal recourse.
We discussed the issue with Leslie M. Kroeger, a partner at the law firm Cohen Milstein Sellers and Toll. She serves as co-chair of Cohen Milstein’s Complex Tort Litigation practice. Kroeger has also led several managed care abuse cases, spoken at conferences on this topic, and currently serves as President of the Florida Justice Association.
TheBigRedGuide.com: What is “managed care abuse” and why is it an important topic?
Kroeger: Managed care abuse occurs when your medical insurance provider or HMO breaches its fiduciary duty or contractual responsibilities to you by denying you access to medically necessary care or medication in violation of its healthcare policies and the law. It is often the result of the company prioritizing cost-cutting and profit-making over patient care. This obviously puts the health of the patient at risk. Cohen Milstein has extensive experience litigating managed care abuse claims against insurance companies and HMOs.