A Swansea medical provider says an insurance company has wrongly taken an unknown amount of money from it and others after unfairly refusing to pay portions of medical charges.
Back Doctors filed a putative class action lawsuit May 13 in St. Clair County Circuit Court against MetLife Auto and Home.
Kevin T. Hoerner and Brian T. Kreisler of Belleville, Paul M. Weiss and Jeffrey A. Leon of Freed and Weiss in Chicago and Richard J. Burke of Freed ad Weiss in St. Louis will be representing them.
Back Doctors claims MetLife consistently uses a biased computer software called Decision Point to limit and exclude coverage on parts of medical expenses incurred after a covered occurrence. For example, if a person sustains injuries in an automobile collision, MetLife will sometimes use the software to exclude or deny portions of coverage without first determining whether the denied charges are unreasonable, according to the complaint.
"Rather, Decision Point software, such as that used on Plaintiff's claims, simply compares the line-item charge billed for a medical procedure to internal fee schedules imbedded (sic) within the software," the suit states. "Insurers such as Met select a particular 'percentile' payment benchmark (e.g. the 85th percentile), and any amount of the charge that exceeds that payment benchmark is capped and excluded from coverage."
Met does not disclose which percentile benchmark it uses and does not take into account what could be considered a reasonable charge for medical services, the complaint says.
Therefore, when Met uses a code 41/x41 to reduce its insured's claims, it simply reduces the claim without explaining to its clients what it considers to be a reasonable charge, Back Doctors claims.
By using such a code and software to reduce its insured's claims, Met fails to follow its own policy language, according to the complaint. For example, in its policies, Met promises to determine whether a medical charge could be considered reasonable before it refuses payment to its insured, the suit states.
"In spite of this representation, Decision Point simply compares the amount charged for a procedure to fee schedules embedded within the program; the fee schedules are purchased from third party Ingenix – who disclaims any and all warranties behind the data being used to determine payment amounts and who concede that such software does not make 'reasonable' or 'unreasonable' determinations," the complaint says.
Any amount that exceeds the percentile benchmark Met set will not be covered, Back Doctors claims. For example, if Met has set coverage at the 85th percentile, and if the 85th percentile charge is $24 for a particular procedure, but Met is billed $25, it will only pay $24, according to the complaint.
"Met is simply disinterested in whether a medical charge submitted to it is reasonable or not," the suit says. "Met simply wants to employ a systematic means to control Policy payments, which assure profitability of its decisions."
From year to year, Met's insureds are not sure how much money would constitute a reasonable charge because Met may change its percentile benchmarks annually, the complaint says.
"This is not because what constitutes a 'reasonable' or 'unreasonable' charge has changed, nor has what is 'usual' or 'customary' changed, but rather Met's financial circumstance (or 'bottom line'), or litigation 'climate' in which it operates," the suit states. "Met saved untold dollars on claims that it should have paid under the express terms of its policy."
In its two-count complaint, Back Doctors alleges breach of contract and violation of the Illinois Consumer Fraud Act.
It seeks a certification of its class action suit, plus unspecified damages, pre-judgment interest, attorneys' fees, costs and other relief the court deems just.
St. Clair County Circuit Court case number: 10-L-241.