Here's a sad and tragic story about a 17-year-old girl who died. Her insurance company refused to pay for a necessary liver transplant. The company reversed its decision to deny payment hours after the girl died.
Nataline Sarkisyan died last month at the University of California, Los Angeles Medical Center. She had been in a vegetative state for weeks, said her mother, Hilda. The family hired celebrity defense attorney Mark Geragos who said he plans to ask the district attorney to press murder or manslaughter charges against the insurance company in the case. The insurer "maliciously killed her" because it did not want to bear the expense of her transplant and aftercare, Geragos said. The insurance company argued that there was a "lack of medical evidence" that the transplant would actually help the young woman live. After many healthcare professional expressed outrage, the insurance company then reversed its decision hours after the girl's death because it decided to make an "exception" in this case.
You can read more about the story here. Unfortunately, Mr. Geragos has a very steep hill to climb. It's highly doubtful that the prosecutor will take such a case. Instead, Mr. Geragos will get more publicity to help his law practice more so than the girl's grieving family.
The real problem here is the federal legislation known as the Employee Retirement Income Security Act of 1974 (ERISA). The ERISA laws have been significantly changed and modified by corporation and business lobbyists who were able to inject language to encompass, not only pension plans, but any sort of employer plans to benefit employees. The law gives insurance companies the wide discretion to decide on their own what treatment is considered reasonable, necessary and nonexperimental. Essentially, the health plan administrator decides what benefits to pay.
Over the years the federal judiciary enforced ERISA to allow the health plan to serve as the judge and jury on all issues related to whether benefits should be paid. The public does not understand that if they are in a dispute with a health insurance company that is governed by ERISA, as most plans are, the insurance company itself gets to decide whether it should have to pay for health insurance benefits. The federal court will not intervene to help these unfortunate employees and their families who desperately need health insurance benefits. Unfortunately, the insurance health plan covering Natline and her family was subject to ERISA. The federal courts will only reverse the insurance companies if the courts find that the insurance companies have "abused its' discretion" in denying benefits. In layman's terms, what this means is if there is any evidence whatsoever to support an insurance company's denial of benefits, the federal judges will turn their head and ignore this injustice.
Many people fail to realize that virtually all insurance companies have an army of lackeys, usually retired doctors, or doctors who are otherwise incompetent that they can not make a living in the real world, who are willing to place their stamp of approval on the denial of any claim. I call these people "rubber stamp doctors" and they are hired guns to give the insurance company the decision they need to deny benefits. The only way to correct this injustice is to elect congressmen or congresswomen who have the courage and character to change ERISA. I doubt that the federal judiciary, who serve judge terms for life, and are answerable to virtually no one, will ever correct this injustice.
Christopher M. Davis is the managing partner of Davis Law Group. He brings over 15 years of practical yet innovative experience to personal injury cases. He practices law in Seattle, WA. You can learn more about Mr. Davis at http://www.InjuryTrialLawyer.com or http://www.seattleaccidentnews.com .