The inverse order correspondence stream.
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Date:
Wed, 26 Apr 2000 08:51:27 -0700 (PDT)
From:
Subject:
Re: Your Medical Claims
To:
CC:
Todd Watson <twatson@metrogroup.com>,
Sherri Hancock <shancock@metrogroup.com>In the cause of keeping you from deflecting and redirecting, I once again remind you that I have requested the name(s) of ALL First Health Medical Directors AND contract physician consultants that have been involved in BOTH my and my wife's cases (March 1995 to date). This involves more than your disengaging "staff."
If you don't know the name(s) of the First Health Medical Directors, you sure have violated the "prudent man" concept of your fiduciary duties. I know of no other named fiduciary that would be so negligent, putting you outside the mainstream.
After all, you've been blithely upholding this (by your claim, unknown) person's denials for many years, in lieu of exercising your discretionary authority. I find it hard to believe that any "prudent man" would blindly accept any unknown (your claim) person(s) medical decisions over the overwhelming, and accepted, medical literature I and my physician's have provided. You've already stacked the deck by only providing some of the administrative record for final review by the other hired gun. Medicine by phantom? I sure know the name of the person that caused my disability.
During your convenient absence, who becomes The Person Designated As The Agent For Service Of Legal Process? Who remains to pick up the pieces?
James, I have asked First Health to expedite a response to you on both yours and Karen's claims questions. I believe you should be receiving responses soon.
As to your question on the names of First Health physician reviewers, I do not have the names of these staff members. I do not know First Health's policy on release of these names. You may want to write to the First Health corporate attorney, Margaret Jones, about this question. I have already given you the name and credentials of the outside physician reviewer, Dr. Gary Greenhood.
I will be out of the office for several weeks, so if you have questions in the meantime, you may want to direct them to Sherri Hancock (shancock@metrogroup.com).
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Date:
Tue, 25 Apr 2000 07:57:24 -0500
From:
To:
Subject:
Your Medical Claims
CC:
James, I have asked First Health to expedite a response to you on both yours and Karen's claims questions. I believe you should be receiving responses soon.
As to your question on the names of First Health physician reviewers, I do not have the names of these staff members. I do not know First Health's policy on release of these names. You may want to write to the
First Health corporate attorney, Margaret Jones, about this question. I have already given you the name and credentials of the outside physician reviewer, Dr. Gary Greenhood.
I will be out of the office for several weeks, so if you have questions in the meantime, you may want to direct them to Sherri Hancock (shancock@metrogroup.com).
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Linda,
I don't know if you got my last e-mail or not, since you haven't responded. In that e-mail, I requested the name(s) of all First Health Medical Directors and contracted physician consultants who have been in reviewing either my or my wife's files.
From my February 16, 1999 letter to you (also attached) "see also Armstrong v.Jefferson Smurfit Corp., 30 F.3d 11, 12 (1st Cir. 1994) (fiduciary must disclose material facts of which plan participants are unaware but need to know in order to protect their interests in dealing with third parties)."
I really would like your rapid cooperation.
"R. James Martin" <rjamesmartin@yahoo.com> wrote:
Thank you for your response.
It seems you are more worried about protecting First Health than you are in performing your fiducirary duties, ensuring that the benefits of the plan accrue to the beneficiaries. On more than one occasion, I have asked for the name(s) of the First Health Medical Director, and of all the "hired guns" First Health has used to "review" cases. This has been steadfastly ignored by you, and First Health.
With the current investigations going on concerning Medical Directors and "hired guns" going on at the state and federal level, it is imperative that we be accurate in reporting "adverse events." Our requests for compliance being ignored, either omission or commission, is an ethical lapse.
Serious allegations have been made against First Health before, with your action being "let them handle it" being your response.
Substantiated facts are not allegations.
Once again, I have a need for the names of all First Health Medical Directors and contracted physician consultants who have been in reviewing either my or my wife's files. Will you provide them to me?
Either way, I will be testifying at the Senate hearing next month.
LINDA FARINA <LFARINA@metrogroup.com> wrote:James, I have already requested an update from First Health as to when
their response to your letters might be ready. I will let you know when I
receive an answer. I will forward your comments about First Health
lying to the Department of Labor on to First Health counsel, Margaret
Jones.
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"R. James Martin" 04/19/00 09:44am
It's called pulling a Linda Farina; ignoring questions you don't wish to respond to. For example, in the original communciation, I asked a question that you have not responded to. Familiar?LINDA FARINA wrote:
James, I wasn't sure if you got the message I sent yesterday evening since I didn't receive a response from you. You have made a very serious accusation that First Health is lying to the Department of Labor. I would like more information on this from you. Again, as I said earlier, I am not aware of any correspondence whatsoever between First Health and the DOL.
Linda================================================================================
>>> "R. James Martin" 04/17/00 02:11pm
>>>
Thought you might be interested in this. Wasn't there an old commercial that went something like "pay me now, or pay me later?"
First Health seems to be getting slower and slower. Isn't there anything you can do to speed them up? I know they are embroiled in lying to the Department of Labor right now, but should they be neglecting their normal duties?
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National Class-Action Filed Against Prudential Health Care
NEW YORK, April 13 /PRNewswire/ via NewsEdge Corporation -
A federal class-action lawsuit filed this week against Prudential Insurance and its healthcare subsidiaries may affect several million people across the U.S. who are participants in, or beneficiaries of, Prudential employee welfare benefit plans.
The action was filed Tuesday, April 11, 2000, in the United States District Court, District of New Jersey, by two of the preeminent plaintiff class action law firms, Pomerantz Haudek Block Grossman & Gross LLP and Milberg Weiss Bershad Hynes & Lerach LLP, against the Prudential Insurance Company of America and the Prudential Health Care subsidiaries (collectively, "PruCare"). It was filed on behalf of a proposed class of all participants or beneficiaries in employee benefit plans who
have received their health insurance through PruCare. In August 1999, Aetna, Inc. acquired Prudential's health care business.
The case alleges, among other things, that PruCare breached the express terms of its health care plans by using procedures for determining whether proposed care is "medically necessary" that are
inconsistent or conflict with generally accepted medical standards. In particular, plaintiffs claim that PruCare improperly permits non-physicians or physicians who are not qualified in the appropriate specialty to make denials of care based on medical necessity and, further, that in making such decisions PruCare relies on actuarial guidelines developed by Milliman & Robertson, Inc., when such guidelines do not reflect accepted standards within the medical community.
Just this week, Aetna U.S. Healthcare, Inc., Aetna U.S. Healthcare of North Texas, Inc. and Prudential Health Care Plan, Inc. jointly submitted with the Attorney General of the State of Texas a proposed settlement of a case brought by the State of Texas on behalf of its residents. Among other things, Aetna agreed that "the determination of medically necessary care is an analytical process that will be applied by Aetna on a case-by-case basis by qualified professionals who have the appropriate training, education, and experience and who possess the clinical judgment and case-specific information necessary to make these decisions."
In the recently filed Prudential action, plaintiffs allege that their contracts require PruCare to follow this standard and that it has failed to do so. The plaintiffs seek to compel PruCare to comply with its contractual obligations on a nationwide basis, as Aetna has now agreed to do in Texas.
In the settlement, Aetna also agreed that any non-case specific guidelines or policies it uses to determine medical necessity will be publicly disclosed and made available for peer review, to the extent
permissible by applicable law or relevant contracts. In the PruCare complaint, the plaintiffs allege that PruCare relies on the Milliman & Robertson guidelines, which have neither been disclosed nor been made available for peer review. To the extent such guidelines are protected from disclosure by contract, they would not be required to be disclosed under the proposed settlement. In the Prudential action, plaintiffs allege that reliance on the Milliman & Robertson guidelines for determining medical necessity is improper, and seek to compel Prudential Healthcare to alter its decision-making process.
Pomerantz Haudek Block Grossman & Gross LLP (http://www.pomerantzlaw.com), one of the first firms involved in managed care litigation, won a significant decision against Healthsource in 1997 involving the rights of patients under ERISA. The firm recently filed an action on behalf of the American Medical Association and the Medical Society of the State of New York attacking reductions in
reimbursements to providers and patients based on improper determinations of usual, customary and reasonable rates.
Founded by the late Abraham L. Pomerantz, known as the dean of the class action bar, the Pomerantz firm pioneered the field of securities class actions and has recovered numerous multimillion-dollar damages awards on behalf of class members in securities, antitrust and consumer
litigation. The firm has offices in New York and Chicago.
Milberg Weiss Bershad Hynes & Lerach LLP (http://www.milberg.com), a 145-lawyer firm with offices in New York, San Diego, San Francisco, Los Angeles and Boca Raton, has been actively engaged in commercial litigation, emphasizing securities, consumer, insurance, healthcare, human rights and antitrust class actions, for more than 30 years. The firm's reputation for excellence has been recognized on repeated occasions by courts that have appointed it to major positions in complex
multi-district or consolidated litigations. Milberg Weiss has taken a lead role in numerous complex litigations on behalf of defrauded investors, consumers and companies, as well as victims of World War II human rights violations, and has been responsible for more than $20 billion in recoveries.
Milberg Weiss was one of the first law firms in the nation to bring large-scale actions in both federal and state courts challenging managed care organizations' use of undisclosed policies on a plan-wide basis.
R. James Martin -- Euless, Texas
A Tick Made Me Sick
TIICS Are Keeping Me That Way
(The Insurance Industry Captive Specialists)
https://www.angelfire.com/biz/romarkaraoke/james.html
3-10-2000
