Suit accuses United Healthcare of fraud
It says the company enrolled a woman in a Medicare alternative she didn't want.
By STEPHEN NOHLGREN
Published July 25, 2007
» In depth
Victims of fraud can switch back
The 2007 enrollment period for picking a Medicare plan ended more than three months ago, but a little-known rule allows people to switch plans all year long if they were victimized by fraud or misrepresentation.
If you feel you wrongfully ended up in a private plan, call 1-800-Medicare and say you want to qualify for a special enrollment period because you were misled into a plan you didn't want.
A Medicare caseworker will investigate.
How to tell if you've been had
Grounds for disenrollment can include:
• Statements by an agent or company employee that suggest the plan will be accepted by all Medicare providers.
• Statements that imply the plan is a Medicare supplement or Medigap policy.
• Statements that suggest you can switch back to traditional Medicare any time you wish.
Burden of proof
While you don't need to prove your case with documents, you will have to convince Medicare that you are not trying to disenroll from a plan just because you don't like it.
Provide as many dates and details as possible, such as the insurance agent's name or names of other company employees you contacted.
Anything in writing will help, such as any of the insurance agent's cards or sales materials, or notes you took from conversations.
You had until March 31 to disenroll from a private plan. If you wrote any letters asking to disenroll and the company did not take you off its client list, provide copies of that as well.
Sources: Times research, Centers for Medicare and Medicaid Services
ST. PETERSBURG - Like many older people, Charleen Edge finds today's smorgasbord of Medicare plans confusing.
Last year, she says, she found herself in a private health maintenance organization she neither requested nor desired. Her repeated requests to switch back to regular Medicare went for naught. After she broke her pelvis in April, neither Medicare nor the HMO would pay the bills, she says, so she's stuck with the $30,000 tab.
"I have no insurer," says Edge, a 78-year-old retired social worker. "I don't know whether Medicare is going to take me back."
But Edge does have one advantage: a board-certified trial lawyer for a son.
Pinellas Park attorney Joseph Saunders filed a class action suit Monday in Pinellas-Pasco Circuit Court, alleging that UnitedHealthcare of Florida committed fraud and breach of contract by enrolling his mother into a HMO when all she wanted was one of the company's Medicare Part D drug plans.
The company compounded the fraud, the suit claims, by refusing to disenroll her when she asked.
The suit estimates that 5,000 other Floridians are in the same boat, a figure Saunders acknowledged he picked out of the air after recent congressional testimony alleged widespread sales abuse within the industry.
UnitedHealthcare, with 60,000 Medicare members in Florida, did not commit fraud and has zero tolerance for sales abuses, said Peter Ashkenaz, vice president for communications for the parent corporation.
"We focus our efforts on providing access to high-quality care and customer service," he said. "We are investigating the complaints alleged in the lawsuit filed today by Mrs. Edge and her attorney to ensure that all her claims are paid according to the terms of her plan."
Medicare does not discuss beneficiary business with third parties like reporters.
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Charleen Edge is more than competent to handle her own affairs, her son says. She earned a master's degree at age 50 and worked for Northwestern University's hospital system before moving to St. Petersburg four years ago.
UnitedHealthcare contacted her in late 2005 or early 2006 because she had a high-end AARP Medicare supplement policy that was about to be rendered obsolete by the new Part D program Medicare was offering.
Edge would be better off with two AARP policies, the company said: a cheaper supplement plan plus a new drug plan. Both work in conjunction with traditional, fee-for-service Medicare.
Fine, she said.
In April 2006, however, Medicare began to reject her doctor bills. UnitedHealthcare had signed her up to the company Medicare HMO. Since Medicare paid the HMO a flat monthly rate for her care, Medicare would not pay non-HMO providers to treat her as well.
Edge wrote a letter to UnitedHealthcare on April 19, 2006, asking to disenroll her in the program after a telephone call wouldn't do it. No one responded, her suit says.
At the end of 2006, UnitedHealthcare did notify her that she would be enrolled in the company's HMO for 2007. After Saunders wrote to complain, the suit says, the company wrote back in January that it had disenrolled her.
Four months later, she tripped and broke her pelvis, requiring five days in a hospital and 50 days of rehabilitation at a nursing home.
According to the suit, UnitedHealthcare confirmed to the nursing home's billing director that it had disenrolled Edge in January. But Medicare rejected all the bills, including ambulance and doctor bills.
According to Medicare, UnitedHealthcare indicated it had re-enrolled her into the HMO in February, the suit says. That was two months before she fell.
On top of everything, Saunders said, UnitedHealthcare has been rejecting her mother's bills from the AARP drug policy, even as it continues to deduct premiums from her bank account.
"I didn't see this as a case at first. I was just trying help her as a son," he said.
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Saunders is no stranger to cases with multiple clients. He has represented people in class action litigation over diet drugs and faulty medical devices. He negotiated a global settlement for more than a dozen men who said they were abused by Catholic priests in the St. Petersburg diocese. He is married to Kathy Saunders, who occasionally writes freelance stories for the Times.
Because his mother is now lead plaintiff in a class action suit, he said, she will have to pursue the case on behalf of other class members even if UnitedHealthcare offers to pay her bills.
The next legal step is a hearing to see if a judge will certify that UnitedHealthcare HMO members represent a class of people suitable to mass litigation.
For the time being, Edge said, she is trying to avoid doctors because she doesn't know whether Medicare, UnitedHealthcare or anyone will pay the bill.
"I've never owed anyone anything," she said.
[Last modified July 25, 2007, 01:35:03]
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