June 9, 1999
From :
R. James Martin
501 Sycamore Lane, #327
Euless, TX 76039
Phone: 817-540-2272
Fax: 817-540-2672
To:
Pension & Welfare Benefit Administration
525 Griffin Street, Rm. 707
Dallas, TX 75202-5025
Phone: 214-767-6831
Fax: 214-767-1055
Subj: Wrongful Denial of Benefits appeal
I am writing to your office for assistance in halting, and correcting, an egregious manipulation of an ERISA plan.
Attached is what my Employee Benefit Plan Named Fiduciary considers my "Final, Full and Fair Review", which followed my contesting an inordinate amount of benefit denials.
The whole farcical process the Named Fiduciary used throughout this travesty is documented on my web-page at https://www.angelfire.com/biz/romarkaraoke/james.html - James Martin's Lyme Disease Horror Story; How Lyme Disease and Exploitation of ERISA Laws Can Destroy A Life.
The basis for my appeal to you is the standard of review utilized by the Named Fiduciary and the remote-reviewing doctor. When taken to court, the usual stumbling block for an appeal is what is contained in the Administrative Record. As can be seen in the Named Fiduciary's letter to me, the remote-reviewing doctor was sent some of my correspondence and some of my research documentation. The exclusion of information from the Administrative Record is neither Full, nor Fair. Following the form of the law is not sufficient, it must be complete and accurate.
Additionally, from the letter, the remote-reviewing doctor introduced publications and literature that were not part of the Administrative Record at the time of review. My points of contention, the supporting documentation introduced, the medical record delivered by my provider, the Plan document, and the First Health Medical Director's information should be the only items reviewed. It is not difficult to find a doctor that will disagree with a procedure or diagnosis, some make a career of it.
Interestingly, from the Named Fiduciary's letter, the following points of curiosity have been raised:
The c.v. cited in the letter does not jibe with that maintained on the American Medical Association's web-page. A disclaimer on that accuracy could most probably be made, since the doctor is not an AMA member, but the doctor is the person responsible for the accuracy of that information. I know of no valid reason why information provided by the doctor to the AMA would differ from that provided to, and contained in the letter from, the Named Fiduciary.
The letter references "(I) the 15th edition (1998) of Harrison's Principles of Internal Medicine." The 15th edition has not yet been published. The 14th edition was published in 1998. In that edition, the section on Lyme Borreliosis was written by Dr. Alan C. Steere, and is quite dated. The recommendations for treatment have been extensively enlarged in recent years, and that information is part of the Administrative Record.
The letter references "(ii) the 1998 Sanford Guide to Antimicrobial Therapy." The 1998 edition is out of print and unavailable to me, the 1999 edition will not be published and available until some time this month.
The opinion expressed by the ERISA specialist retained by MRG; that the MRG Plan document complies with the law; simply remains an opinion. My position on what one would reasonably expect when denied a benefit was stated succinctly in my February 3, 1999 letter (attached) , but was ignored and not addressed.
Is there any way you can address and assist in rectifying this mockery of Congressional intent?
Sincerely,
R. James Martin
cc: Linda Farina
