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TMCNet:  United Healthcare Sued in Federal Court by Hooper, Lundy & Bookman for Alleged Illegal and Discriminatory Denials of Coverage for Lap-Band Surgery Which Addresses Morbid Obesity

[March 24, 2014]

United Healthcare Sued in Federal Court by Hooper, Lundy & Bookman for Alleged Illegal and Discriminatory Denials of Coverage for Lap-Band Surgery Which Addresses Morbid Obesity

LOS ANGELES --(Business Wire)--

United Healthcare, one of the nation's largest health insurance companies, along with hundreds of employer-funded health plans, was sued March 20, 2014 in U.S. Federal District Court in Los Angeles by Hooper, Lundy & Bookman, PC for alleged refusal to pay for Lap-Band surgeries which United Healthcare previously authorized for morbidly obese patients. The complaint alleges a "deliberate, willful and concerted effort" to deny health insurance coverage for lap-band surgery constituting discrimination against the morbidly obese. The plaintiffs in the case are Los Angeles-based surgical centers and physicians to whom the patients went for the Lap-Band surgeries.

"This is a classic case of an insurance company putting profits over people," said Daron Tooch, of the Los Angeles law firm Hooper, Lundy & Bookman that filed the case on behalf of the surgical centers. Tooch stated, "almost everyone in America with health insurance knows exactly what this case is about -- a health insurance company whose employees and representatives are taught to 'just say no' or to delay, delay, delay rather than pay claims for Lap-Band surgery, which has long been recognized as a legitimate basis for dealing with morbidly obese individuals."

The complaint alleges that United authorized hundreds of patients to undergo pre-operative tests to determine whether the patients qualified for the Lap-Band surgery, but refuses to pay for the preoperative tests or the Lap-Band surgeries despite the fact that the patients qualify for the surgery.

p> The complaint alleges that United has created pre-textual excuses for refusing to process or to pay the claims. In many instances, United has refused to pay for post-surgery adjustments to the Lap-Bands. As a result, these patients are unable to receive the additional medically necessary care they need, and to which they are entitled, and are being held financially liable for the care they have already received. Many of these patients are foregoing receiving the necessary medical services because of the financial liability.


The complaint alleges that United:

  • Makes repeated and redundant requests for unspecified medical records, even where records had already been provided on multiple occasions, and when the surgical centers call to find out what specific records are missing, United cannot provide such information.
  • Forwards the surgical center claims for "further review" by United's wholly owned subsidiary, OptumInsight, which apparently is located in the Phillipines, without forwarding the medical records along with the claims. United promises the OptumInsight will take 15-30 days, when in fact the so-called review takes years with no payment resulting from the "review."
  • Asserts that one or more of the surgical facilities was not listed in United's database of health providers as a reason for non-payment, even though claims had previously been paid to those same facilities and even though United sometimes paid the surgeon who performed the surgery.
  • Demands surgery center licenses, even though California does not issue licenses to surgery centers.
  • Denies claims because the patient supposedly did not have coverage, for instance, because of a pre-existing condition, when such coverage in fact existed.

The surgery centers and physicians seek a federal court order requiring United Healthcare and the ERISA plans to honor their obligations owed to the insured employees and to pay for the Lap-Band and related surgical claims in good faith and expeditiously.

About Hooper, Lundy & Bookman, PC: Hooper, Lundy & Bookman's litigation lawyers are regularly engaged in complex litigation involving hospitals and health systems, as well as other health care providers. The firm's litigation department regularly assists provider clients with litigation, arbitration and mediation services that have resulted in numerous favorable judgments and new case law. With clients in 50 states and offices in Los Angeles, San Francisco, San Diego, and Washington, D.C. , the firm is the largest law firm in the country dedicated solely to the representation of health care providers. For more information, visit the firm's website at www.health-law.com.


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