New Lawsuit Alleges Unitedhealth/Pacificare Deceived Cancer Patient

PR Web Newswire ^ | November 18, 2006 | Law Offices of Robert K. Scott

[SBD1]

Just as an FYI, sending a complaint to the Insurance Commissioner or in my case the DMHC, doesn't always give you the results you think they will provide.

After Pacificare refused to pay for the second surgery, I sent a request for an Independent Medical Review of that decision since the surgery needed to be performed right away and Pacificare denied it the day before it was scheduled. The DMHC tricked me into filing a grievance.

This is how they tricked me into filing a Grievance instead of moving forward with the Independent Medical Review. I faxed them the IMR request on June 1. A few days later, I get the letter below which is dated June 2, the very next day. The letter says that I requested the documents, but that is not true. I did not notice it right away because of the well utilized "sticky note". From that sticky note, I assumed I was giving them more information to further my IMR. It turned out that these forms are to file a Grievance.



The DMHC decided for Pacificare because the surgery was not pre-authorized.

I decided to give the DMHC another try, this time for the cancellation issue. Their letter dated October 13, 2006 said that I would receive a decision within 30 days. As of today, nothing. I called them and they said someone would get back to me with an update.

Subsequently, an interesting revelation was announced regarding the DMHC and UnitedHealth/Pacificare. It appears that during the merger, their was a "conflict of interest".

State moves to fire HMO regulator The Schwarzenegger administration is moving to fire a top HMO regulator who held stock in UnitedHealth Group Inc. when he helped review the 2005 acquisition of PacifiCare Health Systems Inc.

Randolph said the department planned to more closely examine its employees' economic interest reports as well as institute a beefed-up in-house ethics training program.

SBD

[khnyny]

[If you have a good case, you try it in court, not in the media. Press releases from law firms generally indicate a strategy of trying to get the defendant to settle to avoid bad publicity, not a desire to litigate a strong case on the merits.]

LOL. Have you ever had a case go through the "court system"? Even if this guy's case is strong, he (if he lives long enough) or his family, could be fighting it for years. BTW, I think part of the intent of going public was to prevent others from the same fate.

[BlazingArizona]

<>Otherwise, what's your alternative?

It's the market (complete with the possibility of enormous payoffs) that leads people to risk their own time and money on untested new treatments, and without such a reward, who would want to take that kind of risk?

It's not a market unless the patients have as free a range of choices as doctors, hospitals and pharma companies. Give the consumer unlimited right to shop around, and perhaps medicine won't have to have socialism shoved up its nether orifice as the populist answer to the many monopoly privileges it enjoys today.

[PAR35]

Have you ever had a case go through the "court system"?

Yes, I just settled with an insurance company about 2 1/2 years after the injury. If a case actually goes to trial, one side (or both) has made a serious miscalculation.

I think part of the intent of going public was to prevent others from the same fate.

His case isn't without issues. From his timetable, the insurance wasn't purchased until after he went in for the initial tests. I wouldn't be surprised if there was something in the boilerplate of the policy covering that situation.

[SBD1]

I did not however have the scan for a "medical condition". Also, under California Law, the insurer must attach a copy of the Application to the policy when issued.

10381.5. The insured shall not be bound by any statement made in an application for a policy unless a copy of such application is attached to or endorsed on the policy when issued as a part thereof.

Also, this case is very similar to mine.

METROPOLITAN LIFE INSURANCE COMPANY, Plaintiff and Appellant, v. JOSEPHINE DEVORE, Individually and as Administratrix, etc., Defendant and Respondent. JOSEPHINE DEVORE, Plaintiff and Respondent, v. METROPOLITAN LIFE INSURANCE COMPANY, Defendant and Appellant. (Consolidated Cases)

L. A. No. 27982

Supreme Court of California

Prior to his death, the insured signed an amended insurance application about one month after the initial application, which amendment provided that the insured "confirmed the statements therein made as of the date hereof." The insurer contended that the statement referred to the date of the amendment, and not the date of the initial application, thus making the insured's answers fraudulent. The court held that the date provision was ambiguous, and in view of the rule that ambiguities must be interpreted against the insurer, the insured could have reasonably understood that he was confirming the answers in his original application. The court held that the rule that a representation was presumed to be made at the completion of the insurance contract, was a rebuttable presumption. The court found that the presumption was properly rebutted by findings that the representations were referable to an earlier time. The court held that the insurer could not rely on the "good health" provision of its conditional insurability because the insured reasonably believed he was in good health at the effective date of the policy and his doctor had not informed him of his new illness.

SBD