Insurance Fraud Litigation
Insurance Fraud Litigation
Our firm represents clients in first party medical payments cases and total loss litigation cases against various insurance companies. They are:
Medical Payment Cases:
First Party Auto
The first type occurs when a person is injured in a car accident and incurs medical expenses. The medical expenses are submitted for payment under the insured's medical payments portion of their automobile insurance policy. Typically, the policy states it will pay all reasonable expenses for necessary medical treatment up to the policy limits, which are usually $2,000, $5,000 or $10,000.
However, what actually happens is the insurance company hires a third party company, such as CorVel, Mitchell Medical or ADP to take the bill and run it through a computer database system. This computer system is designed to unilaterally reduce the amount of the bill to a predetermined percentile amount. In fact, insurance companies choose themselves what percentile they would like the bills reduced to. You may see reductions based on "the prevailing rates for medical providers within your geographic area" or charges reduced on "usual, customary and reasonable" grounds. These determinations are not based on legitimate data but systematically decided by a computer program.
"Silent-PPO"
The second type of case occurs when a medical professional submits his or her patient's medical bills for payment and the insurance company reduces the bills based on a Preferred Provider Option ("PPO") contract between the medical provider and the insurance company or a broker for the insurance company (such as CorVel, CCN, or Focus), when in fact:
1) there is no such contract; 2) there is a contract, however, the insurance company or broker has failed to provide the "channeling" or "steerage" as required by the contract - that is, they failed to set up an actual PPO; or 3) there is a contract, but the broker or insurance company sold the medical provider's name to other insurance carriers who fail to provide channeling or steerage. Because of the secret nature of these hidden "PPO" reductions, this practice is referred to as a "Silent PPO."
Workers' Compensation
The third type of case occurs when a medical professional is treating a patient that has a worker's compensation claim and the insurance company reduces the payment to the doctor by either using a third party company as discussed above or by applying a Silent-PPO discount that it is not entitled to. Nowhere does the worker's compensation insurance policy give the carrier the right to use third party computer database systems to reduce payment or to apply discounts that they are not entitled to.
