U.S. Appellate Court Confirms the Limited Power of Health Insurance Companies

When it comes to how health insurers conduct themselves, everyone seems to believe that their power is virtually endless. Provider contracts have more and more onerous terms, with each passing year, and efforts to get all doctors in network continues apace. The “non par” out of network practices are feeling the pinch, and they too believe that the power of the health insurance industry is being wielded effectively against them.

But, what if the Emperor had no clothes? What if their power was illusory; it exists because we allow it to exist. In the law, always look for the source of someone’s power. Is it in a law passed by Congress? Is this person or entity allowed to conduct itself in a particular manner because courts have made decisions, setting legal precedent, that allows the conduct to continue unabated?

Well, here’s the news: the Emperors (health insurance companies) have virtually no clothes when it comes to how health plan claims are supposed to be be handled. Their conduct, as the U.S. Supreme Court — and now another U.S. Court of Appeals has confirmed — is guided by the “plan documents” and the ERISA claims regulations promulgated by the U. S. Department of Labor. The plan documents are the health plans that employees receive from their employers or sponsoring organization, as a group benefit, in the workplace.

The website pages, manuals, and various portions of the health insurer’s provider agreements are not the guiding light. ERISA wipes them out, with a rule called “pre-emption”.

You need only be willing to listen to what the law is and to use its power in the right way. Quadrino Law Group, with its 21 years of national ERISA experience, uses the law in this manner, for the benefit of medical providers across the country.

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