UnitedHealthcare hit with ERISA lawsuit for allegedly reversing an approved claim
The insurer did not give an explanation for the reversal of coverage for a midwife, leaving a couple with no recourse after exhausting all processes within the claims processing, including a formal appeal, which was denied.
UnitedHealthcare and Oxford Health Insurance were hit with an Employee Retirement Income Security Act lawsuit in U.S. District Court in Connecticut. The plaintiffs alleged that the defendant wrongfully denied coverage of a midwife after initially authorizing the care as in network.
Plaintiffs Jonathan A. Winter, Rebecca E. Moore and their son contended that UnitedHealthcare, Oxford Health Plans LLC and Oxford Health Insurance Inc. changed course regarding the midwife after the baby was born, the complaint said.
Winter, Moore’s husband, is also the attorney representing himself, his wife and son in this case. A partner at St. Onge Steward Johnston & Reens, Winter declined to comment due to pending litigation.
UnitedHealthcare and Oxford Health Insurance did not immediately respond to requests for for comment.
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The complaint said the plaintiffs received a letter from the defendants stating that the midwife’s services were approved, and there was no communication that modified or retracted the approval.
Moore and Winter had used the same midwife for their other child, without an issue, the complaint said.
In addition, the complaint alleged that a UnitedHealthcare representative encouraged the plaintiffs not to file a lawsuit, and to go through the internal appeals process since the midwife was previously approved.
“Plaintiffs have exhausted all processes within defendant’s internal claims processing, including multiple telephone calls explaining the situation and a formal appeal to defendant’s appeals department, which was denied,” the complaint said.
The complaint said that the plaintiffs were also not given an explanation for the reversal of the claim.
“Plaintiff brings this action pursuant to ERISA and the [Affordable Care Act], Connecticut State insurance laws and the common law to recover the benefits due under the [insurance] plan,” the complaint said, to enforce the plaintiffs’ rights under the plan and the ACA, and to seek appropriate equitable and legal relief, including compensatory damages, interest, attorney fees and costs.