Hello. I'm a lawyer in South Florida desperately trying to obtain an approval for medical treatment needed by my son, and Anthem is refusing to authorize for reimbursment. Anthem, has indidcated that the insurance provided by my wife's employer is pursuant to a self funded ERISA plan.
Anthem denied the initial request for authorization for the treatment recommended by my son's doctor. The treatment which requires hospitalization will cost in excess of $40,000. The denial by Anthem was totally ambiguous. Anthem's denial letter indicated that the proposed treatment was not "medically necessary." I appealed the decision and that was denied. I asked for an external appeal and was told by the State of Virginia Insurance Commissioner, where I sought the external appeal, that self funded ERISA plans have a different kind of "external appeal." The external reviewers are not chosen by the State Insurance office, but rather by Anthem who contracts out these external appeals.
Prior to submitting the external appeal file, Anthem asked whether I wanted to supplement the file. I asked several times whether the denial was based on a decisiion that my son was not suffering the medical illness diagnosed by his doctor or whether the denial was based on the recommended treatement (this was never clarified in the inital denial letter). I needed to know this in order to determine what kind of additional records to be submitted in support of our claim; to wit: records suppporting the diagnosis or records supporting the appropriateness of the treatment. I received several responses that continued to cover both basis. I questioned how Anthem could challenge the diagnosis based only on the clinical office notes and lab results submitted by my son's treating physician without Anthem's "deciders" conducting a clinical exam of my son. No response. Anthem's "external review" folks, have recently declined my request that they speak directly with my son's doctor on the teleophone before making a decision.
I have no hope that the external reviewers selected by Anthem will reverse the decsion denying benefits. Accordingly, I am going to have to pay for the treatment myself and seek reimsbursment by way of litigation.
This is where I need help. Who would be the defendant in a lawsuit seeking reimbursement? Anthem? The self funding employer (Virginia based). Both?
Could I file the lawsuit in Florida where I live since I would be the Plaintiff seeking reimbursement? Would it have to be in Federal District Court? If not, Florida, would I file it in Virginia where the self funding employer is located and could I leave the employer out of the lawsuit (preferable to me since the insurance is through my ex-wife's employment and wouldn't want to create litigation that would harm her relationship with the employer). If the suit is only against Anthem, could I file and keep the suit in Florida, state court or more likely, Federal Court?
I am pretty sure that Anthem is doing this with all children suffering the same ailment as my son. His treating physician says that a number of other insurance companies approve the treatment based upon her diagnosis but she always has denials from Anthem. Apparently, Anthem makes the insured parents jump through the appeals process hoops in the hopes that a lot of parents of kids sick with the same ailment as my son will not have the resources or knowlege to get through the process.
Im quite comfortable that in litigation I have experts who will support both the diagnosis and recommended treatement as appropriate. One of them would be the Chief of the Pediatrics & Developmental Neuroscience Branch at the US National Institute of Mental Health Can I bring a class action for declaratory releif to establish that the diagnosis and treatment recommended is appropriate for all similarly situated children who are diagnosed with the same ailment and are fighting for the same treatment and join in any insurer who has been routinely denying reimbursement for the recommended treatement?
Any help will be greatly appreciated...
Reed
