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

  • the arguments you made on our behalf at the mediation resulted in a more positive outcome for our case than we could have otherwise expected.

    “We appreciate that you found merit in our case, and that you were both willing and able to be present at the mediation. We believe that the arguments you made in our favor to the mediator were able to influence the outcome towards resolution that we could feel satisfied with. In the end, we believe that your counsel, your support, and the arguments you made on our behalf at the mediation resulted in a more positive outcome for our case than we could have otherwise expected. Throughout you were always professional, but direct and clearly firm on our position. We thank you for your efforts to resolve our dispute to our satisfaction, and wish you continued success.”

    Mara T.

  • 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.

  • 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.

  • First of all, I want to express my extreme gratitude for probably saving my daughter's life.

    “First of all, I want to express my extreme gratitude for probably saving my daughter's life. By staying in treatment, the improvement is remarkable. She had been in eating disorder facilities many times, and treatment had been interrupted repeatedly by Anthem Blue Cross's denying benefits. Many of the health professionals were telling me that maybe my daughter was a hopeless case. You both gave me hope. She is still struggling with some residual issues around eating, but the change in her attitude, her ability to assess her own recovery, and her wish to live instead of to die, is evident in her life. Now she is back in school, after years of having her education disrupted by the eating disorder. She goes places with friends, and even goes out to restaurants for fun! This year marked the first holiday season for many years, when she had not been in a treatment facility. Other people gave up and you didn't. I can't thank you enough. You took the action that was necessary to keep my daughter in treatment long enough for it to work.”

    Anonymous

  • I won the appeal.

    “Hi Glenn- This is a very belated thank you for your generous assistance and advice last summer, when I was appealing UBH's decision for my son. I won the appeal, at least for care at the partial hospitalization level (they wouldn't budge on residential, but the facility was accepting the partial care reimbursement for residential treatment). But the appeal was a great moral victory, and I think it's a great thing to have in the record, just in case he needs to go for treatment again. Thanks again for your generous help, I was very grateful for it. Wishing you a most happy Thanksgiving.”

    Terry S.