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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
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Client Testimonials

  • 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

  • I am a life you have touched. May God bless you richly.

    “After suffering with constant pain for nearly seven months, losing the job I loved and then being denied my long term disability, I was extremely discouraged when I began looking for help. With a few phone calls from Mr. Kantor to my insurance company, my long term disability was reinstated . The financial burden was lifted and I have hope again. I am a life you have touched. May God bless you richly.”

    Susan H.

  • With you in my corner, I felt enabled and no longer alone.

    “Seemingly at the end of my rope with nowhere to turn, a friend suggested I call the National Multiple Sclerosis Society, who referred me to you. From our first contact I began to feel hope where there had been none. You took over all communication with the insurance company. You kept me posted as things progressed and advised me as to each necessary action. What a relief you were! With you in my corner, I felt enabled and no longer alone. Some big insurance companies feel emboldened to take arbitrary action against those who do not have the resources to defend what is rightfully theirs. Thank goodness for people like you who advocate for folks in need. In closing, please know how very much our association has meant. You have restored my faith in the goodness of people and renewed my confidence in the future. I am forever grateful.”

    Shirley G.

  • Thank you for all of your hard work, support and belief in our case.

    “Hi Elizabeth - You have been such an important part of my and Jennifer's past year, and I want to send you a note to wish you a wonderful holiday. Thank you for all of your hard work, support and belief in our case. Thank you seems like two small words and not enough, but they are heartfelt and mean so much.”

    J.H.

  • Thank God for Kantor & Kantor.

    “Thank God for Kantor & Kantor and Denise Anderson. I appreciate everything you do!”

    Stephen Schaffer