Woman On “Inside” of Health Care Benefits Learns The Hard Way About Being On “Outside”

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Judy Lerner – Studio City, CA

As told by Judy Lerner:

I was a principal with one of the largest benefits consulting firms in the world. As an "insider" in the world of employee benefits for twenty years, I was a defender of the "system" until I found out the hard way about the abuses in the managed care industry– I lived it.

On June 21, 1996, I fell down the stairs at home, fracturing my right leg in three places, dislocating my right ankle and fracturing my left foot. After undergoing emergency surgery, I emerged with casts on both legs and five pins and a plate in my right leg. I spent nearly three months confined in my third-floor bedroom, totally immobile. The physical torture alone and the long road to recovery would have been enough of a burden to bear; but my medical plan and my employer turned it into a nightmare.

My health care plan denied payment for medically necessary ambulance transportation to my doctor’s office for follow-up care, even though I could not get into a normal vehicle, had to be carried down the stairs and had coverage under a medical plan whose legal plan document says it pays for transportation in an emergency or for medical necessity.

Three weeks after my accident, my health care plan also tried to cut off my home health care, even though I was immobile and totally dependent on trained assistance for every bodily function, medical need and activity of daily life. A few weeks later, my home health benefits were actually terminated, forcing me to pay for them myself. My health care plan contended that I should be able to go up and down three flights of stairs on crutches—even though I had casts on both legs, suffered from vertigo and initially became injured by falling down the stairs!

I have continued to appeal, without success, these outrageous denials of medical benefits that go against the very provisions of the plan itself, as well as against the orders and opinions of all my treating health care providers.

And, to make matters worse, my employer’s actions when I returned to work aggravated a chronic illness I have, rendering me incapacitated. But to no surprise, my employer also has denied my long-term disability benefits–even though I was approved for Social Security disability (the strictest disability standard to meet). Medical and disability benefits are expensive and my employer loses nothing by delaying and denying them.

Unfortunately, ERISA precludes me from seeking compensatory or punitive damages. Unbeknownst to the public at large, in today’s health care environment, if an employer or its benefit plan denies care improperly and the patient is irreparably damaged, or even dies, the only action available is a suit for the amount of benefits denied; legal fees are not even guaranteed — even if the plaintiff succeeds.

The majority of employees in this country have some form of employee benefits coverage that by and large they don’t understand. In "normal" situations, more and more people are having trouble getting their expenses paid under their benefit plans; in cases of serious accident, catastrophic disease and chronic illness, the problems in getting benefits paid are staggering.

No matter how egregious the violation of law or good faith, benefits law does not allow an employee to sue the employer or it’s benefits plan for damages–even if denied medical care results in irreparable bodily harm or death. People in this country need straight talk about what to expect from their benefit plans and how to get what they deserve: they need the story their employers will never tell them.

The ERISA loophole must be challenged and changed or more and more individuals will find themselves trapped in a no-win situation that leaves them with nowhere to turn and the health care industry immune from legal responsibility for denying or delaying medically appropriate care.

Consumer Watchdog
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