Class action claims Sentry improperly reduces medpay

Steve Gonzalez Jan. 3, 2005, 8:14pm

One of the last lawsuits filed in Madison County Circuit Court in 2004 came at the hands of chiropractor Daniel Jones D.C., owner of Bunker Hill Chiropractic Clinic. He filed a class action suit against Sentry Insurance Company Dec. 30, alleging it improperly reduces payouts under medical payment (medpay) coverage.

According to Jones, Sentry uses biased third party audit software programs to unfairly adjust medical expense claims. His suit is the second by a Madison County chiropractor against Sentry. Mark Eavenson, D.C., filed a class action lawsuit against Sentry on Oct. 14, 2003 (03 L 1402).

In the latest suit against Sentry, Jones claims the insurance company does not do what its policies require. Instead, Sentry systematically reduces its payments by “re-pricing” the submitted bills arbitrarily using biased computer software, according to the suit.

“Sentry’s computer software manipulates computer codes to arbitrarily reduce payouts by incorporating secret treatment guidelines into the system that deny treatment as purportedly not necessary when these guidelines are violated," the complaint states. "Sentry also manipulates computer codes to reduce prices through practices known as bundling and downcoding.”

Jones claims that by failing to pay reasonable expenses for necessary medical treatment, Sentry allegedly breached its duties under its insurance contracts.

He also claims that Sentry violated the Illinois Consumer Fraud Act (and other states) because its computer generated payment limitations are not disclosed in the policies.

Even though Sentry promised to pay all reasonable medical expenses for necessary medical services, Sentry partially denied treatment as unnecessary, according to the complaint.

“To implement its Medpay claims reduction scheme, Sentry disseminated uniform instructional and training literature to its employees, which instructed them on how to reduce Medpay claims payouts through the adversarial use of computer reports,” the complaint states.

Jones, represented by The Lakin Law Firm of Wood River and Freed & Weiss of Chicago is seeking an amount not to exceed $75,000 per plaintiff, plus all costs and reasonable attorney fees.

The case has been assigned to Circuit Judge George Moran Jr.
04 L 1433

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