Representing Clients Throughout California
No-Cost Consultations

Call or fill out the form below for a
no-cost consultation.

  • Please enter your name.
  • This isn't a valid email address.
    Please enter your email address.
  • This isn't a valid phone number.
    Please enter your phone number.
    You entered an invalid number.
  • Please enter a message.
    Please select an option.
Client Focused. Court Room Ready.

Kantor & Kantor, LLP Lawyers Win Trial Victory

For Client Fighting Employer's Self-Funded Health Plan

Kantor & Kantor, LLP lawyers won an important trial court decision recently on behalf of our client whose employer's self-funded health plan denied medical benefits for her son. The court determined that the plan administrator had abused her discretion and violated our client's statutory rights in refusing benefits for her son's medical expenses. The court instructed the plan to process the claims in accordance with plan terms.

Martinez v. The Beverly Hills Hotels and Bungalows Employee Benefit Trust Employee Welfare Plan

Ana Martinez is employed by Beverly Hills Hotel and Bungalows and is a covered participant in Beverly Hills Hotel and Bungalows' ("BHH") self-funded employee benefits plan, which refused to cover medical and nursing care for her son in a "persistent vegetative state" from injuries incurred while he was at school. His care averages $13,000 a month. A special needs trust was created following a settlement with the school.

BHH's employee benefits plan was previously funded through an insurance policy with Blue Cross. Blue Cross paid for medical care for Ana's son and never sought reimbursement from the special needs trust.

BHH ended its contract with Blue Cross and went self-funded on Jan. 1, 2008. Immediately upon becoming self-funded, the plan requested that Ana sign a "Right to Reimbursement" agreement that would permit the plan to seek reimbursement for any of her son's care from his special needs trust. BHH refused to even "process" any of Steve's claims without the reimbursement agreement signed. The court found no basis for the plan's request that Ana sign the reimbursement agreement before the plan would process medical claims.

In addition, when BHH went self-funded, the plan asserted for the first time subrogation rights. The plan alleged that the special needs trust must pay for the medical care and only when the trust funds were depleted would the plan agree to provide medical benefits. The court found that the plan's language was clear: the hotel was not entitled to subrogation rights from special needs trusts.

The court also found that the plan had a conflict of interest in that the administrator responsible for the plan finances was also the responsible for making benefit determinations. At trial, the plan administrator testified that "she put the plans interests ahead of the participants' interests," a violation of ERISA law. Plan administrators are charged with a standard of care that mandates discharge of their duties solely in the interests of plan beneficiaries.

This lawsuit is only one example of the ways benefits plans attempt to deny coverage for legitimate claims. As health insurance premiums rise, more and more employers are self-funding plans with provisions that could interrupt your benefits under previous plans or deny ongoing coverage.

If you are involved in a disability benefits dispute with your employer's self-funded plan, we can help. Contact us today. 

What Sets Us Apart?

  • Free Case Consultations Provided
  • 160+ Years' Collective Experience
  • Thousands Of Cases Successfully Handled
  • You Don't Pay Us Unless We Recover Your Claim
  • Selected For Inclusion In The List Of Super Lawyers®

Client Testimonials

  • I am so grateful for all your efforts and I'm sure glad you were on my side fighting for me.

    “Dear Alan - I just wanted to send you a special note of thanks for all your hard work on behalf of me and my case. I am so grateful for all your efforts and I'm sure glad you were on my side fighting for me.”

    Tracy R.

  • You've helped to remove a great burden from our lives. It's nice to know there are decent people still in the world.

    “Thank you for your kind efforts. You've helped to remove a great burden from our lives. It's nice to know there are decent people still in the world.”

    B.

  • Truly outstanding in every way!

    “Both Glenn Kantor and his associate attorney Brent Brehm are truly experts in the field of disability law. They handled a complex individual disability policy issue for me. Their knowledge of the law, coupled with their experience, resources, and tactical skills, helped me obtain results that exceeded my expectations. Truly outstanding in every way!”

    Anonymous

  • Your compassion for me and my situation is very much appreciated.

    “My thanks to you for pursuing my case with vigor. I don't know much about how these legal things are handled, but I could tell by your communications with me, making sure I was always informed, that you were on top of it all. Also, you were ALWAYS available to me to answer questions, and your compassion for me and my situation is very much appreciated. I have had limited exposure to the legal system and attorneys, but I have never been able to just call and talk to them, as I could with you. I always had to speak with someone in the office that couldn't really answer my questions.”

    D.B.

  • Thank you a zillion times for your patience and time and absolutely helpful information.

    “Thank you a zillion times for your patience and time and absolutely helpful information. You've helped me understand my position with my disability insurance and payments so much better. There is some real comfort in feeling anchored in knowledge…of what is and what might be in the future. Thanks to you!”

    B.