Michigan Personal Injury Blog - blue Shield

Special Needs Children Pay When Insurance Companies Don’t

David Mittleman — Tue, 30 Jun 2009 14:29:44 GMT

Last week I posted an article about Blue Cross Blue Shield and its agreement to pay families of autistic children a total of $1 million for behavioral therapy coverage. Although this settlement is a step in the right direction, health plans have a long way to go before children with special needs receive fair treatment.

Developmental problems are pervasive in their nature. They affect nearly every aspect of a child’s life. Some disorders, such as birth-trauma induced cerebral palsy, impact both the mental and the physical development of the child. As a result, these children often require specialized equipment, supplies, services, or devices able-bodied children do not need.

Unfortunately, health plans and insurance companies characterize such special requirements as not "medically necessary" - almost always at the plan administrator’s sole discretion - and deny these benefits. As a result, many families are forced to pay expenses out of pocket or to make the unsettling choice of forcing their child to do without the needed benefit. Compounding the insult is the fact that the law makes it exceedingly difficult to reverse the decision of the plan administrator.

One glaring example of the anti-consumer state of the law is the Employee Retirement Income Security Act (ERISA). Originally designed as a measure to protect workers and ensure they would receive the promised benefits of their employment, a series of court decisions over the past two decades gave plan administrators tremendous authority to deny claims. Only very recently have some Courts begun ruling in favor of individuals instead of corporations.

The time period in which to challenge an adverse decision is usually very limited. If your health plan has denied a claim you believe you are entitled to, contact us to see if we can help.

Originally posted at InjuryBoard by David Mittleman

Blue Cross Blue Shield to Pay $1 Million to Families of Autistic Children

David Mittleman — Fri, 26 Jun 2009 11:32:09 GMT

Blue Cross Blue Shield has agreed to pay $1 million dollars total to families that sought coverage for behavioral therapy for their young autistic children and were denied. The settlement money will go to approximately 100 families, including those that were denied coverage or who had to pay the cost of the therapy out-of-pocket.

The federal lawsuit was filed in U.S. District Court in Detroit after the families were denied because Blue Cross Blue Shield deemed the therapy “experimental”. Blue Cross Blue Shield has since changed their policies regarding autism therapy: beginning last month they started offering therapy to autistic children from ages 2-5. However, they still maintain that they consider the treatment “investigational and experimental”.

All of the children named in the lawsuit were treated at an autism center operated by William Beaumont Hospitals in Royal Oak, Michigan. The specific therapy offered at the hospital aims to help children address common social and communication issues associated with autism. Early intervention is considered key to helping autistic children develop at a similar rate to their non-autistic peers.

Originally posted at InjuryBoard by David Mittleman

BCBS of Michigan Picked A Terrible Time to Increase Rates

David Mittleman — Tue, 03 Feb 2009 09:51:59 GMT

It is no secret that times are tough in Michigan. The state has the highest unemployment rate in the country which has forced thousands of people to purchase individual health insurance plans that were once employer-sponsored. As if Michigan residents haven’t suffered enough from the recessionary state of the economy, Blue Cross Blue Shield of Michigan is attempting to make things worse.

On January 30, 2009, the company filed a rate of increase request with the Michigan Office of Insurance and Regulation to hike monthly premiums of over 400,000 Michigan residents who are on individual policy plans. The request outlines increases of 31% to 56%, depending on the type of policy. The increase only affects those residents who have an individual plan or who have supplemental Medicare coverage - in other words, the increase is going to disproportionately raise the rates of those people who are already struggling.

BCBS claims the increase is necessary to offset a projected $1 billion loss from 2009 to 2011. According to a statement posted on the BCBS website, the losses are due to a failed and outdated regulatory system which places the burden on BCBS of insuring the costliest individuals. In addition to increasing rates, the company plans to cut 1,000 employees throughout 2009 and has placed a freeze on executive and non-union worker salaries.

Originally posted at InjuryBoard by David Mittleman

Health Insurers Propose to Accept All Applicants, With One Big Condition

David Mittleman — Fri, 28 Nov 2008 13:53:00 GMT

Last Wednesday, Health insurers released proposals to accept all applicants, regardless of preexisting disease or disability, IF Congress mandates all Americans have coverage. Although the "if" is a huge condition, it is also a huge step in the direction towards universal health care coverage. With newly-announced support from the health industry’s two largest trade associations, America’’s Health Insurance Plans and Blue Cross Blue Shield Association, the plan is likely to reform the health care system as President- elect Barack Obama takes office in a few months. However, Obama’s plan only mandates health care coverage for all children, as he opposes a mandate for adults, which could prove to be a point of contention between lawmakers.

In our current health care system, many people with preexisting diseases and illnesses cannot get health insurance at any cost. If the system changed and heath insurers were forced to accept all applicants, absent the universal coverage provision, insurers fear people will wait until they become sick before buying insurance, ultimately driving up the cost for everyone. However, by imposing a universal coverage condition, healthier individuals will off-set the sick, which will drive premiums and prices down for all. According to Alissa Fox, Vice President of Blue Cross Blue Shield Association, "Insurance works best when everyone is in the pool. You need healthy people in the insurance pool to help pay for sicker individuals who are much more motivated to buy coverage."

Supporters of the legislation would like the bill to pass sometime next year; however, it remains to be seen exactly how the premiums will work and how the mandate will be enforced. With the economy on a downward spiral and more and more people losing their jobs and employer-sponsored health care, a universal system may be the only answer, and the mandate might not look too bad after all.

Originally posted at InjuryBoard by David Mittleman

Medicare Refuses to Pay For Medical Mistakes And Doctor's Negligence

David Mittleman — Thu, 09 Oct 2008 15:46:48 GMT

Starting October 1, Medicare announced it will no longer pay for treatment resulting from medical errors which occurred during a hospital stay. What does this mean to the over 44 million Americans depending on the program for benefits? Basically, if you are further injured while in your doctor’s care, Medicare will not cover the additional costs associated with the treatment.

Medicare’s new policy is based on a list of "never events," which are theoretically never supposed to happen. When one of these events does occur, Medicare will no longer bear the burden and instead will require the hospital to report and pay for the error. The problem with these so-called "never events" is that over the years they have become more and more accepted by doctors as conditions that can and will occur. In fact, "never events" account for between 44,000 and 98,000 deaths each year. The "never events" list includes malpractice and negligent behavior such as foreign object left in body after surgery, operating on the wrong body part, falls and trauma, bed sores, infections at the surgical site, and other preventable problems.

This bizarre policy does not just apply to individuals under government aid, rather, several large private insurers including Blue Cross Blue Shield, Aetna, Cigna, and WellPoint have considered or implemented a similar "never events" system. The theory driving this policy is a pay-for-performance trend. Prior to this policy, there were practically no financial penalties for hospitals when a preventable "never event" occurred. Now, the hospitals are responsible for the costs associated with extended stay and extra procedures; the regulations forbid the hospitals from charging patients.

Although this policy is expected to save dollars and lives, the real question remains as to who will pay for the innocent patients’ additional pain and suffering and unnecessary time off work. Should the hospitals, doctors, or both be accountable? After all, if a doctor's action (or lack thereof) meets one of the 28 conditions on the "never events" list, which in turn forces the hospital to cover the costs, is this evidence of negligent behavior or medical malpractice?

Originally posted at InjuryBoard by David Mittleman