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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
  • 160+ Years' Collective Experience
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Client Testimonials

  • You have restored my faith in the goodness of people!

    “Thank you Glenn for accepting my case. I had all but given up on finding an attorney that was willing to take this case, and although you may not remember, I enclosed a note to you when I sent my [ins. co.] file asking you to please help me. You did that sir, and I can't thank you enough. My thanks to you Corinne 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 so 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. My sincerest thanks and best wishes for you both You have restored my faith in the goodness of people!”

    Dick H.

  • 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.

  • Your kindness will never be forgotten.

    “Dear Glenn, Several weeks ago, you graciously met with my husband and me and provided us with invaluable advice vis a vis his application for Long Term Disability and the Voluntary Transition Plan offered by his employer. Your calming presence and thoughtful guidance was so gratefully appreciated and we both felt much lighter as we left your office. We are pleased to advise you that David's application for LTD was approved the day after we met with you (sigh of relief)! Had it not been, we knew when were we would go for representation. We both want to thank you for your thoughtfulness and generosity of spirit. Your kindness will never be forgotten. With Warmest Regards, Lori and David C.”

    Lori & David

  • there are no words that can express the feelings of gratitude and relief I have that you helped us

    “I wanted to thank you again for all of your help. My daughter would not be in treatment without your help. I can never thank you enough, there are no words that can express the feelings of gratitude and relief I have that you helped us, and I believe saved my little girl. Taking her back to Timberline Knolls was very difficult in many ways, I wish UBH could know the damage they have done to her by having her go in and out like this. When she went into Timberline Knolls the first time she was not happy to go exactly, no one wants to go into treatment, but she was open to going in and ready, for the first time, to really look at her issues and work hard to get better. When she had to leave Timberline she expressed that she wished she could have stayed because she felt like she was finally at a place where she was getting better and, though it was hard, she was really opening up and dealing with her issues for the first time, something she has had a hard time doing. I just wanted you to know that she was going down to a really bad place and without you I don't know what would have happened except that she would not be at Timberline Knolls right now getting better and I thought you should know this. With unending gratitude.”

    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.