Daniel Jones, D.C., who filed a class action suit against State Farm Fire & Casualty, will be in court this week on a motion to amend his complaint and proposed order against the insurance company.
Jones, a chiropractor in Alton, alleges State Farm systematically and improperly reduced medical bills submitted by licensed medical providers covered under medical payments (Medpay). Jones, who filed the suit in April 2003, claims that State Farm used a computerized database program to systematically and secretly cap payments to him and other members of the class.
He also alleges State Farm failed to pay him and others the full amount of medical expenses for services provided by them and covered by policies written by State Farm.
According to the complaint filed by Richard Burke of the Lakin Law Firm in Wood River, this case involves the issues of “reasonableness” and “necessity,” but does not involve the issue of relatedness. The complaint states that State Farm paid the claim in part, thus conceding that the claim was related to an occurrence covered by the State Farm policy.
The suit claims that State Farm used capped payments for covered medical expenses by denying medical expenses as unreasonable, using code “668” whenever the expenses exceeded a secret percentile of the rates for usual, customary and reasonable charges made by the medical provider in the region where the treatment was rendered.
Jones also contends State Farm used the computer system to cap payments by denying licensed medical treatment as not medically necessary using code “309.” In that case, State Farm would arbitrarily change the code assigned to a particular service to a less expensive one, according to the complaint.
Based on State Farm's alleged scheme and common course of conduct to limit medical payments to an undisclosed cap with the potential for further retroactive reductions, he makes claims on behalf of himself and all others for breach of contract, declaratory judgment, and violation of the Illinois Consumer Fraud and Deceptive Business Act, 815 ILCS 505/1 and the similar laws of other states.
Jones also alleges that State Farm uses arbitration to further its scheme so that the claimant does not challenge the company. However, it then compromises the challenge by “splitting the baby” (settling for an amount greater than the computer report-derived amount, but less than the submitted bills).
Since the Medpay underpaid claims are usually less than $1,000, it would be impossible for Jones and others to pursue the arbitration process because they would have to spend more in arbitration-related costs than the disputed claim amount. State Farm knew this when it issued this clause as part of its alleged fraudulent scheme, according to the complaint.
Jones seeks no relief, cause of action, remedy or damages that would confer federal jurisdiction upon the claims asserted, and expressly disclaims individual damages in excess of $75,000 and causes of action arising under laws of the United States.
State Farm is represented by Heyl, Royster, Voelker, and Allen of Edwardsville.
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