The Conflict Of Interest Inherit In Administrative Review

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The Conflict Of Interest Inherit In Administrative Review

The Conflict of Interest Inherit in Administrative Review
and the Ineffectiveness of the Current Standard of
Review by U.S. District Courts
Law and Medicine
By # ________
I. Introduction
The Employee Retirement Income Security Act, better known as ERISA, has been a major issue in healthcare litigation since its inception in 1974. ERISA governs any claim centering on health insurance, disability insurance, or any other employer provided benefits. ERISA affects many aspects of the American legal system, from inter-state commerce to bankruptcy, and particularly insurance and healthcare law. ERISA contains clauses for both the procedure and substance of the law and is often preemptive over state law. There is a great deal of misunderstanding and confusion surrounding the application and coverage of ERISA, which has made litigation even more complex and hazardous. Understanding the basic procedure, coverage and intricacies of ERISA's implications and formalities is essential for any attorney practicing insurance or healthcare law.
This past year I was personally involved in an ERISA litigation suit. This suit involved a woman working for The Mutual of Omaha Companies. She was denied a breast reduction surgery by her employer-run health plan. This surgery had been recommended by her physician and deemed medically necessary. However, her health insurance plan exempted all forms of breast surgery, not involving cancer, from coverage regardless of their necessity. Our client, the insurance participant (client) then came to our office to see what assistance we could provide in helping her obtain coverage for this surgery.
At this point, our office thought that the chances for recovery of any benefits were very slim due to the fact that the health insurance policy specifically excluded breast reduction surgery from coverage. However, we told the client we would look into the possibility of recovery. With very little investigation we were able to discover that although the health insurance policy had excluded breast reduction surgery, Mutual of Omaha had previously granted coverage to three of the exact same types of surgery to more senior Mutual of Omaha employees within the past year. Thereafter, our case quickly became a question of whether the healthcare administrator was precluded from denying coverage for breast reduction surgery, when it had granted coverage for the same on three previous occasio...

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