After Resolution Of Contract Negotiations, Is Damage To Members Ignored? ERISA Class Action Filed Over Medical Claim Denials; Alleges Thousands Of Pre-Approved Medical Claims Unpaid, Members Left Holding The Bag; Possibly Delay Ratification Process?
On February 26, 2015, just days after the Obama Administration sent in Labor Chief Thomas Perez and a settlement was negotiated between ILWU members and the PMA, the International Longshore Workers Union-PMA Coastwise Welfare Plan was slapped with a new class-action lawsuit alleging ERISA violations and fraud for its failure to pay possibly hundreds of millions of dollars in pre-approved benefit claims, as reported by the Los Angeles Times newspaper. The lawsuit offers hope to the thousands of members that have had pre-authorized claims denied, according to court records.
“This is about protecting the rights of American workers. It is unconscionable that a health plan would deny pre-authorized, covered medical claims from a cancer patient, thereby denying needed chemotherapy. Every health plan must comply with all applicable federal laws, ERISA and PPACA claims regulations, as well as statutory fiduciary duties, for the millions of hard-working American workers and families. Otherwise we will have a real life John Q on our hands.” said Esmeralda Alfaro, Co-Lead Counsel for the class plaintiffs.
Despite protests from thousands of ILWU members throughout CA and numerous “work stoppages” over the last 2 years and a formal complaint to the Department of Labor, EBSA Assistance and Complaints, the PMA welfare plan has allegedly refused to pay pre-authorized medical claims. The result has been calamitous for members and their relatives according to the court documents. Many have foregone much needed medical care and some have had mortgage loan applications denied due to adverse credit ratings linked directly to unpaid medical claims.
According to the complaint, the Plan’s own independent fact finder confirmed there were “286,000 unprocessed claims” at one point and the “backlog became worse, with about 90,000 new claims each month” added to the backlog. The suit also alleges that the plan attempted to “delay processing of legitimate claims, increasing interest income for the Plan’s fund” as well as create the “misimpression that the PMA Trustees have been diligent in the exercise of their fiduciary obligations”, according to court documents.
In accordance with this ERISA class action filing, Avym Corporation announces new comprehensive ERISA and PPACA Out-Of-Network (ONET) Medical Claim Appeal and Litigation Support Programs in accordance with the most recent federal court decisions. Avym Corporation provided plaintiff providers with ERISA appeal compliance and ERISA litigation support in this provider ERISA class action and Avym’s support services were instrumental in allowing multiple plaintiffs the chance to fight back.
Case Info: Amijo et al v. ILWU-PMA Coastwise et al U.S. District Court for the Central District of CA (Western Division- Los Angeles) Civil Docket for Case #: 2:15-cv-1403, Filed 02/26/2015.
This class action lawsuit comes on the heels of successful contract negotiations between the International Longshore Workers Union and the Pacific Maritime Association, a group of West Coast terminal operators. While the settlements still have to be ratified by union members, it remains unclear whether ILWU members view the class action lawsuit as an obstacle to delaying the ratification process. The implications of any delay in ratifying the agreements could be enormous.
According to the lawsuit,
- ILWU-PMA has been intentionally withholding and delaying payments from patients and providers on legitimate claims, thereby increasing interest payments to the Plan’s fund in violation of ERISA;
- ILWU-PMA misleads patients and providers by creating the “misimpression that the PMA Trustees have been diligent in the exercise of their fiduciary obligations” when in fact the claim back log was increasing at a rate of 90,000 additional claims per month;
- ILWU-PMA has never complied with ERISA claims regulation nor its own claims procedures by failing to provide “meaningful grievance and appeal procedures” effectively denying full and fair reviews of appealed claims in violation of ERISA;
- ILWU-PMA’s refusal to pay claims has resulted in many members and their beneficiaries foregoing medical care or treatment that is covered by the Plan to avoid damage to their credit rating or additional personal liability for covered services not paid by the Plan;
- ILWU-PMA has intentionally discouraged members and beneficiaries from seeking services from Out-of-Network providers due to the prospect of complete denials of covered, pre-authorized services, in violation of ERISA;
The putative class on behalf of all similarly situated members and providers is seeking for ERISA benefits payments due, injunctive and declaratory relief and removal of the PMA Trustees among other claims.
Avym Corporation’s ONET UCR ERISA Medical Claim Appeals and Litigation Support Programs will systematically demystify this ERISA class action lawsuit, with particular focus on the essential elements of ERISA claims regulation, successful ERISA administrative appeals as the prerequisites for ERISA judicial reviews on behalf of all similarly situated patients and healthcare providers.
The class action also alleges additional ERISA violations by ILWU-PMA for withholding newly adjudicated claim payments even after the claims were “pre-authorized” and or “pre-priced” by the plan and it’s agents. In particular, the complaint alleged the plan “now routinely denies, or fails even to process, most or all new claims for services of out-of-network Providers.”
The Complaint goes on to allege that: “Plaintiffs are informed and believe, and based thereon aver, that Defendants have paid only a few claims for reimbursement for medical expenses for services of out-of-network Providers in over one year, causing financial hardship to Participants and Beneficiaries, who by contract or otherwise are liable to Providers if the Plan does not pay. Such intentional refusals to pay also cause hardship to Providers, who are owed substantial sums, and make it increasingly difficult for Providers to continue to serve Participants and Beneficiaries, because of the growing realization that they will not be paid timely or at all.”
This ILWU-PMA case illustrates the need for all employer sponsored health plans to comply with federal ERISA regulations when making benefits determinations and payments. Additionally, Providers need to level the playing field by ensuring they submit ERISA/PPACA compliant appeals which properly request due process and a full and fair review.
Located in Los Angeles, CA, AVYM is a leading provider of services focusing entirely on the resolution of denied or disputed medical insurance claims by participating in the nation’s first ERISA PPACA Claims Appeals Certification program. AVYM also offers free Webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support services.