Legal Question in Insurance Law in California

The Run Around

We found out for the first time on 9/24/02 that my mother has not been covered under her employers health insurance plan since 12/31/02. My mother received no notification. They say they sent it. We recieved a benefits confirmation sent on 12/19/01 stating she was covered under their basic care. We found out when she wanted to see a doctor about abdominal discomfort. She wasn't covered so she didn't see a doctor until she was rushed to the ER. the doctors said chirrhosis of the liver and it could be treated but they didn't want to because the treatment needs to be monitored and she doesn't have a PCP. Thousands of dollars and 2 months later she is getting progressively worse and now needs a transplant. I am getting no compassion or cooperation with her insurance company and have paperwork showing that she should have been covered. In the two months since this started my mother has been to the ER 4 more times and the bills keep piling up and I am just about to crack trying to deal with it all while my mother gets worse. What can I do? Please help us.


Asked on 11/05/02, 1:04 pm

3 Answers from Attorneys
Jeffrey D. Olster Russakow, Ryan & Johnson

Re: The Run Around

Your mother may have a right to coverage and additional types of recourse, including monetary damages, against the health plan, but an attorney will need to review the factual chronology and paper trail of documents to properly analyze the situation.

Please feel free to give me a call at 626.683.8869.

Jeff Olster

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Answered on 11/06/02, 3:39 pm
Armen Tashjian Law Offices of Armen M. Tashjian

Re: The Run Around

Your mom might have a case based on breach of contract, breach of the covenant for good faith and fair dealing, etc. However, the case must be carefully scrutinized before a lawsuit is undertaken. Consult an attorney or call me at (323)782-0099.

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Answered on 11/06/02, 9:14 pm
Steven Murray Steven W. Murray, APC

Re: The Run Around

You have a potential dual liability situation - the employer may have some responsibility here besides the insurer. In fact, the employer may be the insurer's agent for some purposes. There are some state laws regulating this kind of problem, separate from the insurance laws/case law concerning the insurer and the policy (which is governed by ERISA, the federal employee benefits law.)

This is an extremely complicated area of labor/insurance/contract law, and if an HMO is also involved, add an extra layer.

Why was she dropped? How was the premium paid - by payroll deduction, or did the employer pay all?What about others - was the employer not paying the whole group plan and not telling the employees? The details of how and why (and who) are crucial to knowing how to proceed.

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Answered on 11/09/02, 11:33 am


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