This document is intended to serve as a case summary for the web site detail.

Ms. Linda Farina, acting in her capacity as the named fiduciary for the Metromedia Restaurant Group employee benefit plan, has allowed, through her own action or inaction, the following to occur:

1. For Karen J. Rose, as beneficiary of her spouse’s MRG employee benefit plan, Ms. Farina has failed to act upon outstanding claims for 1995. Despite repeated written and verbal requests, outstanding claims for 1995 have not been released for processing.

a. During 1995, Karen was an enrollee of the LabCorp employee benefit plan; as such, any claim to the MRG plan for 1995 falls under the "coordination of benefits" clause. Under this clause, MRG’s liability extends only to the plan benefit allowed amount normally paid by MRG, minus any reimbursement by other plans.

b. As an example, if a procedure or supply claim is submitted for $3.00, and the LabCorps plan benefit allowed amount is $1.00, and the MRG plan benefit allowed amount is $2.00, then MRG has the obligation to pay 80% of the $1.00 difference in the plans. Where MRG’s plan benefit allowed amount is larger than the LabCorp benefit plan allowed amount, 80% of the difference is due and payable. Where MRG’s benefit plan allowed amount is equal to, or less than, the LabCorp benefit plan allowed amount, no adjustment is forthcoming.

c. Approximately 75% of the 1995 claims have been processed using the "coordination of benefits" clause, with reimbursement due and paid on a significant portion, although in insignificant amounts. The 25% of claims that has been the subject of so many letters, faxes, e-mails, and phone calls, still have not been released for processing. Only when the claims are released and processed will anyone know whether LabCorp or MRG has the higher plan benefit amount.

2. For Karen J. Rose, as beneficiary of her spouse’s employee benefit plan, Ms. Farina has failed to act upon all claims submitted from June 1, 1998 to date. On June 1, 1998, MRG became the primary employee benefit plan for Karen. The "official" explanation is that First Health Strategies, acting as Third Party Administrator for the MRG employee benefit plan, is waiting for requested medical information. This "explanation" is invalid, given that the medical record information requested has been sent multiple times, return receipt requested (returned and filed).

3. For R. James Martin, an enrollee of the MRG employee benefit plan, during an appeal for denial of claims for 1996 and 1997, did not provide the independent medical reviewer with the complete administrative record. Further, she allowed additional documents not part of the administrative record at the time of review to be introduced. The appeal reversed some denials, and upheld some denials. It is felt that the contents of the administrative record would have reversed all denials on appeal; it was only the introduction of additional materials that provided the basis for upholding the denial. Of note, the independent medical reviewer was terminated one month following the review.

4. For R. James Martin, an enrollee of the MRG employee benefit plan; with the exception of claims 927816390024 and 927816390014, Ms. Farina has failed to act upon all claims for 1998 and 1999. The "official explanation" is that First Health Strategies, acting as Third Party Administrator for the MRG employee benefit plan, is waiting for requested medical information. This "explanation" is invalid, given that the medical record information requested has been sent multiple times, return receipt requested (returned and filed).

R. James Martin is receiving long-term disability from a policy purchased through MRG, and receiving Social Security Disability Insurance.

Mr. Martin’s case prognosis is poor, with the following diagnosis:

Lyme Disease	Memory Loss	Immunodeficiency with Leukopenia
Lyme Arthritis	Depression, Secondary	Spasticity
Lyme Meningoencephalitis	Anxiety	Hypertension
Optic Neuritis	Panic Disorder	Bilateral Maxillary and Ethmoid Sinusitis
Cognitive Dysfunction	Facial Palsy	Cerebral Cortical Atrophy
Chronic DVT	Protein-C Clotting Disorder	Intractable Pain
Demyelination, right	Peripheral neuropathies, right	C.O.P.D.

While trying to not sound bitter, it would seem that only a complete idiot could not see "medical necessity" when a neurologist submits procedure and supply claims to treat the above.

Action on my American’s with Disabilities Act (ADA) accomodation request will have to wait until I return to work.

Note: MRG corporate counsel has been informed of the above numerous times, with no action. The only communication was a letter to request that I use corporate e-mail less.