Anthem Sued Over Improper Claim Processing in Violation of ERISA

An employee and her spouse filed suit against Anthem Insurance Companies, Inc. and related entities on Wednesday in the District of Idaho. The complaint explains that the defendants improperly processed some of the plaintiffs medical claims in violation of ERISA.

The plaintiff, per the complaint, is a medically disabled participant and beneficiary of her employer’s group medical plan. The plan is titled the “employee welfare benefit plan.” Plaintiff Merkel is Henderson’s spouse and receives indirect benefits through the plan.

The plaintiff’s employer, the Chevron Corporation, has designated her as an inactive employee since 2010 when a medical disability caused her to be unable to work. Under the aforementioned plan, the plaintiffs both benefit from a long-term disability employer-paid benefits plan. In addition to Chevron Medical Plan, the plaintiff said she is eligible for and receives medical benefits through Medicare.

In 2017, Anthem was designated as the claims administrator for the plaintiff’s plan, at which point they began “receiving adverse claims decisions” that adhered to “arbitrary and capricious administration standards.” The inconsistent way that the defendants dealt with claims under the plan eventually began to interfere with plaintiff Henderson’s ongoing and medically necessary treatment.

Anthem completely removed the plaintiff’s spouse from the plan in 2019, the complaint said. After “months of communications and negotiations,” he was reinstated in the plan but was also subject to adverse claims decisions.

The defendants also misclassified many of the plaintiff’s medical providers as out-of-network providers when they were in-network. This misclassification results in a significant change in the plaintiff’s out-of-pocket deductible since in-network services are covered at a higher rate than out-of-network services. The plaintiffs claim that for this reason, they exclusively seek out in-network providers.

After experiencing frequent issues with the defendants, the plaintiffs filed a claim with the Department of Labor Employee Benefits Security Administration (DOL), who in turn issued four demand letters to the defendants. The letters detailed at least 67 incorrectly processed claims where the provider had been falsely designated as out-of-network.

Eventually, Anthem responded to the DOL letters and agreed to overturn some of the previous coverage decisions, but not all claims. The plaintiffs engaged in the ongoing dispute with the defendants, even hiring legal counsel to pursue further appeals which were continually denied by the defendants. On October 7, 2021, Anthem sent the plaintiffs letters which informed them that the defendants had “supplied and answered all requested information as it relates to this appeal,” despite no documents or explanations of benefits being provided.

The plaintiffs allege that they have suffered and will continue to suffer damages “in the form of attorney fees and expenses related to procuring Plan documents and claim file information that they have requested since March 30, 2021.”

The complaint cites a violation the defendants’ alleged violation of ERISA. They are seeking all Plan documents and claim file materials and payments each day until those materials are produced, for the defendants to reprocess the “out-of-network” claims, declaratory and injunctive relief, pre and post-judgment interest, litigation fees, and any other relief deemed appropriate by the court.

The plaintiffs are represented by Hepworth Law Offices.