Medical Provider Files Class Action Lawsuit AgainstMetLife Over Alleged Use Of Decision Point Software To Limit, Exclude and Deny Coverage Of Medical Expense Charges Without Allegedly Determining Whether The Charges Were Unreasonable.
A class action lawsuit was filed against MetLife Auto and Home insurance company in St. Clair County Circuit Court in Illinois (St. Clair County Circuit Court Case No. 10-L-241), alleging that MetLife uses a biased computer software program called Decision Point to limit, exclude or deny coverage on parts of medical expenses incurred after a covered occurrence without first determining whether the denied charges are unreasonable, according to a class action lawsuit news report.
The MetLife Decision Point class action lawsuit complaint reportedly alleges that Decision Point software used by MetLife compares the line-item charge billed for a medical procedure to internal fee schedules within the software (allegedly purchased from third party Ingenix) and that insurers such as MetLife select a particular “percentile” payment benchmark (e.g. the 85th percentile), and any amount of the charge that exceeds that payment benchmark is capped and excluded from coverage.
The complaint reportedly alleges that when Met Life, for example, uses a code 41/x41 to reduce its insured’s claims, it does not disclose which percentile benchmark it uses and does not take into account what could be considered a reasonable charge for medical services.
The MetLife class action complaint reportedly asserts claims for breach of contract and violation of the Illinois Consumer Fraud Act.
If You Have Thoughts On The MetLife Decision Point Software Class Action Lawsuit, Share Your Class Action Comments Below.
I went on long term disability in 2008 and they(metlife) threatened to take my benefits away it I didnt apply… I applied and waited for a long time but during this time metlife called and sent letters evry month concerning my disability coverage through the state and then took my coverage away due to one doctor not sending any information in, I tried to call the doctor and he said he sent the requested information I explained to metlife that the doctor they were speaking of, I had only seen once and I changed because he was not attentive and they said that they never recieved anything and theat I needed the only office note and that I needed to send it to them so I went and got a copy of it and sent it to them, then they said that there wan’t enough supporting information to approve me and for 5 months I was barely able to feed my kids and almost lost my car I was under so much stress and then I got approved for my SSD and then bam!, metlife approved me and then wanted 9k from the 14k that I recieved and 3k went to lawyers. I did this with no problem although I didnt quite understand how I would pay for this insurance, get benefits and then have to pay them back????? So then they tried to threaten me saying they would take my benefits away if I didnt apply for child disablity payments. In january they had ‘thier’ (doctor) review my file and determined that I was able to stand for 4 hours a day along with lifting 5 lbs and sitting 4 hours a day and also that i could bend over repetively as long as I had breaks, then in June (after having prblems with my health ins. i called metlife to let them know that i cannot go to my doctor until i got my insurance squared away) they took advatage of that and did another review after they just did one in May (never did this before). They took my payemtns away without any denial letter and didnt have any explanation other than that they had ‘their'(doctor) yet again, look over my file and determined that I was now able to stand,walk,lift,bend and sit for 6-8 hours straight a day… NONE of this is true, I cannot do any of this for more than 1 hour tops and that depends on the day. So then I got my payment for my children and now they want 7k from me which after adding up from 2/2010 – 7/2010 @ 503.00 a month comes out to just over 2,500 dollars. I already paid them the back pay that they claim they were “owed”. I refuse to pay them and am seeking counsel…. There are alot of people who are doing the same and If there is a class action lawsuit filed over this I want to be a part of it. Feel free to contact me at any time. This has cause more stress than being sick and they made me worse.
Thanks Desirea