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Tag Archives: peer review

The Basics of an ERISA Life, Health and Disability Insurance Claim – Part Six: Independent Medical Evaluations and Peer Reviews

Posted in: Disability Insurance, ERISA, Insurance Litigation Blog September 26, 2019

In this several-part blog series titled The Basics of an ERISA Life, Health and Disability Insurance Claim, we discuss the basics of an ERISA life, health, accidental death and dismemberment and disability claim, from navigating a claim, to handling a claim denial and through preparing a case for litigation.  In Part Six of this series, we discuss Independent Medical Evaluations and Peer Reviews.  Our focus in this article will be mostly on disability insurance claim denials.

When an insurer examines a disability claim or appeal, it has the medical records examined by medical evaluators, typically a nurse or doctor.  In theory, this allows the insurer to determine whether the claim has merit.  In practice, it is typically a way …

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CBS' 60 Minutes Segment “Denied” Highlights Insurers’ Wrongful Denial of Mental Health Claims

Posted in: Health Insurance, Insurance Commissioner December 16, 2014

On Sunday December 14, 2014, CBS’ 60 Minutes program contained a segment entitled “Denied” which highlights that insurers routinely deny, based on lack of medical necessity, treatment for patients with mental illnesses, especially those for long-term in-patient care at mental health facilities.  This segment was an indictment of health insurance companies’ actions (especially Anthem Blue Cross) to deny legitimate claims for such care, sometimes with tragic results.  According to 60 Minutes, “we found that the vast majority of claims are routine but the insurance industry aggressively reviews the cost of chronic cases.  Long-term care is often denied by insurance company doctors who never see the patient.  As a result, some seriously ill patients are discharged from hospitals over the objections …

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