AARP Foundation lawyers today announced on behalf of the plaintiffs it represents, Flora and Thomas Turpin, of Morgantown, West Virginia that the parties have reached a settlement of the class action lawsuit Turpin v. Highmark, Inc., Case No. 99-1886. The plaintiffs, both older adults, faced a situation that could happen to many Americans as they navigate the sometimes complicated terrain of health insurance and benefits claims.
Flora Turpin, who received medical benefits through her husband's employee health plan, was never told that she had to sign up for Medicare Part B in order to continue her long-time eligibility under the plan. Highmark denied payments for medical service and sent computerized Explanation of Benefit (EOB) forms to the Turpins. These forms, which are widely used by health insurance companies such as Highmark, as well as by HMOs, did not explain why the claims were denied, according to plaintiffs’ claims. Unfortunately, by the time the Turpins had the right answers, the Medicare enrollment window had closed and she was unable to enroll and become entitled to health care benefits under the plan.
The Turpins filed the lawsuit on their own behalf and on behalf of the more than 2.5 million participants in health plans administered or insured by Highmark. The lawsuit alleged that the computerized EOB forms, which are distributed by Highmark when it denies payment of medical claims, failed to provide plan members with adequate information as to why claims for benefits had been rejected and how these members might appeal the benefit denials.
Highmark is the largest health insurer in Pennsylvania. It provides Blue Shield coverage in the Commonwealth and Blue Cross coverage in parts of it. It uses standardized EOB forms in processing all benefit claims. Plaintiffs contended that the forms did not comply with regulations under the federal Employee Retirement Income Security Act (“ERISA”). Those regulations require that benefit claim denials include (1) reference to the specific health insurance plan provisions on which a denial is based and (2) the name and address of the person or entity to whom an appeal may be made.
According to another of the plaintiffs’ attorneys, Jeffrey Lewis, of Lewis, Feinberg, Renaker & Jackson, P.C., Highmark is by no means alone in using forms that fail to comply with ERISA. “Use of computerized EOB forms like those formerly used by Highmark is widespread in the health insurance industry, and hinders American workers and their families from easily obtaining information necessary to understand why insurers and HMOs are not paying promised benefits, and prevents them from easily appealing in order to get those benefits paid.”
The settlement, which was preliminarily approved by U.S. District Court Judge David Cercone of the Western District of Pennsylvania, resolves all of the named plaintiffs’ and class members’ claims against Hallmark in exchange for extensive revisions in the contents of the computerized EOB forms. Further, thousands of current and former participants in plans administered by Highmark will now have the opportunity to re-open previously denied claims and potentially have them paid by Highmark. The company, which changed its EOBs several years after the lawsuit was filed so as to include the name and address of the person or entity to whom an appeal can be taken, also agreed in the settlement to continue doing so in the future.