Anthem sued for alleged 'inconsistent' claims processing

An Idaho woman and her spouse filed a lawsuit against Anthem April 13 for allegedly violating the Employee Retirement Income Security Act by improperly processing their medical claims.

The plaintiff, Martha Henderson, is a medically disabled participant and beneficiary of a group medical plan offered through her employer, Chevron Corp. Perry Merkel is Ms. Henderson's husband and receives indirect benefits from the group policy.

Ms. Henderson has been considered an inactive employee since 2010 because of a medical disability but receives long-term disability under the Chevron plan. Ms. Henderson also receives Medicare benefits.

Anthem has been the claims administrator for the Chevron plan since 2017. In 2018, the lawsuit claims, the payer's "arbitrary and opaque claims administration procedures began to interfere with Henderson's ongoing and medically necessary treatment."

In 2019, Anthem removed Mr. Merkel from the Chevron plan. Following "months of communications and negotiations," Mr. Merkel was added back on, but the payer "began applying arbitrary and capricious administration standards to Merkel's medically necessary care as well."

Anthem is also accused of misclassifying the plaintiffs' in-network providers as out-of-network, leading to higher deductibles.

In 2020, the plaintiffs filed a claim with the U.S. Department of Labor Employee Benefits Security Administration, which issued four demand letters to Anthem. The letters "identified dozens of claims … that had been processed incorrectly on behalf of Henderson."

Anthem responded to the letters and reversed its decision on some of the prior claims decisions, but not all.

The plaintiffs are now seeking all plan documents and claim file materials;, a daily $100 payment for both plaintiffs starting April 29, 2021, until all mentioned materials are produced; reprocessing of the out-of-network claims as in-network; declaratory and injunctive relief regarding proper coding of in-network providers; pre- and post-judgment interest, and litigation fees.

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