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THE ANALYSIS OF A CLAIM

In the months to come, we will be reporting on the various illegal and unethical business behavior of various insurance companies as uncovered in court proceedings by judges and juries in different states. Insurance companies such as Allstate, State Farm, Farmers and others will be in the spotlight and the cases will cover the gamut from wrongful death to the inappropriate utilization of generic auto body parts.

We start with the reporting on the results of the "Goodrich vs. Aetna" case and how the behavior of Aetna disclosed in court can affect you and 125 million of your neighbors.

In this Analysis of a Claim section, we are going to be analyzing the different types of claims that the citizen/ consumer might have against an insurance company; their own company and/or the insurance company of a second, or more, parties. We will be reporting on the findings of juries and judges across the country concerning different types of insurance claims: (1) Auto Injury claims; Those covered under the managed health care programs such as PIP that policyholders opt for, and claims handled directly through an insurance company's claims department (2) Workers Compensation Injury Claims (3) Personal Injury or extended physical disability, emotional trauma and horrendous financial damage to citizen/consumers.

This damage to citizen/consumers has continued for several decades due to public apathy, corrupt politicians and callous insurance executives who earn billions of dollars yearly in compensation while increasing the assets of their companies by tax exempt trillions of dollars annually; all while citizens have died, become disabled and have had their quality of life greatly diminished. Suggest everybody see the movie " The Rainmaker" starring Danny De Vito for a good look at the truth of how certain insurance companies operate!!

Foreword to Goodrich Vs Aetna:

The Insurance consumer/citizen, legislators, the media, government regulatory agencies and prosecutors need to be aware of the violence committed daily by certain insurance companies against the physical, emotional and financial wellbeing and quality of life of everyday citizens. Citizens like Mr. Goodrich and his widow who have experienced first hand the results of the criminal and unethical business practices of the insurance executives who run certain insurance companies. Companies that have amassed trillions of dollars in assets. These insurance executives have been setting policies and procedures that constitute bad faith business practices that result in one or more of the following to many injured claimants: (1) Death! (2) Permanent or extended disabilities (3) Severe financial harm and/or bankruptcy. (4) Emotional and mental trauma for injured party and their loved ones and associates. You, your loved ones and associates may experience the insurance companies illegal and unethical business practices that result in the four negative consequences outlined above whether you have experienced an injury, illness, workers comp claim, or other form of damage to your physical, emotional and financial wellbeing and quality of life. Please Read On!

Goodrich Vs Aetna: (Type of Claim is a #4 as described above)

The first claim and accompanying lawsuit we wish to examine was brought to a CA court and heard by a Judge and a jury of our peers. The lawsuit was filed on behalf of the widow of her deceased husband, David Goodrich. He died because the health care insurance company denied benefits to Mr. Goodrich had managed care health insurance through his employer. Because David Goodrich was a government employee, the legal action for wrongful death and financial harm taken on behalf of his estate and his widow was able to go to court. Approximately 125 million everyday citizens covered under insurance company managed health care programs are not allowed to bring our insurance company " bad faith/wrongful death" lawsuits before a jury because, in the words of the Judge, " (insurance companies) are generally immune from civil suits arising out of the provision of managed health care, based upon the provisions of ERISA." The Federal ERISA Act prevents you and I from bringing lawsuits for insurance company "bad faith". This "bad faith" may result in the death of you or a loved on, mental and emotional trauma and severe financial damage waiting for the timely delivery of essential health care services or the payments of claims that are pennies on the dollar or never come!

Goodrich Vs. Aetna Health Plans of Southern California.

Aetna Insurance was found guilty by a jury in CA of letting this man, David Goodrich, a government prosecutor, die a painful death from cancer resulting from Aetna's denial of the timely delivery of essential health care services. The Aetna health care policy was submitted to the court by the attorneys representing David Goodrich's widow; Attorneys Michael J Bidart and Ricardo Echeve of the law firm of Shernoff, Bidart, Darras & Dillon in Claremont, CA. The following description of what happened to Mr. Goodrich is from a commentary authored by these two attorneys and published in Mealey's Publications; April 28,1999. "The policy was found to not contain any exclusions or limitations to the health care treatments recommended by the Aetna in-plan cancer doctor's (oncologist)." The oncologist's request for cancer treatment for Mr. Goodrich was made on July 21,1992. The Aetna response denying the high dose chemotherapy treatment and bone marrow transplant recommendation came from Aetna four months later on November 18,1992. In the interim, Mr. Goodrich's stomach cancer spread to his liver.

Aetna claims processors used a " Terminal Illness Policy" procedures and guidelines process to deny treatment to Mr. Goodrich even though the Mr. Goodrich's insurance policy did not contain any exclusions for experimental or investigational procedures. Furthermore the " Terminal Illness Policy" guidelines were never disclosed to the in- plan treating physicians or the health care policyholders/members of this Aetna Plan.

The second major treatment request was on August 26, 1993 when David's primary care physician requested authorization for David to be seen in consultation and possible cryosurgery at St. John's Medical Center. Aetna claims department again waited two and a half months to reply (on Nov 3, 1993) and they indicated that "out of plan" services would not be covered. Aetna later paid for the cryosurgery but not for the follow-up chemotherapy. (Since when is chemotherapy an experimental procedure?)

The third major segment of David's treatment was on January 11. 1995 when his In Plan Primary Care Physician requested an out of plan hospitalization for debunking surgery and chemotherapy. David did not have the luxury of waiting months for Aetna's reply so the surgery was performed on Jan 17, 1995. While he was on a respirator in the ICU ward, Aetna delivered another denial for health care services. David died two months later leaving his widow responsible for all the medical bills accumulated over several years; $750,000.

The widow, Teresa Goodrich, a kindergarten teacher, sought the help of the primary care physician to appeal to Aetna to reconsider their decision to deny payment of health care services Mr. Goodrich approved on his own in order to try to stay alive. The letter of appeal was sent to Aetna on May 16, 1995.
Aetna responded in November of 1995, six months later, at which time Aetna again denied it's responsibilities in this case. (Editor's note: I sure hope you do not have Aetna as a health care provider!)

A direct quote from the attorneys for the widow " The Goodrich case was one of the only few HMO (read managed health care) bad faith cases to actually reach a jury. The large majority of managed health care plans covering individuals are obtained through employee benefit plans and therefore are preempted by ERISA. (This means that you and I cannot sue an insurance company managed care health plan for bad faith even if they kill us like they did Mr. Goodrich because our corrupt politicians have passed a federal law (The ERISA Act) that removes our right to sue for bad faith, wrongful death and punitive damages). Under ERISA, those individuals cannot bring their case before a jury to hold the HMO accountable when treated unfairly. Indeed the only remedy available under ERISA is that the managed care plan must pay what it owed in the first place. (Not of much value when you are dead or dying, permanently or experiencing extended injury or illness coupled with financial loss of income and assets.) However, because David Goodrich was a government employee (Aetna must have forgotten about Mr. Goodrich's exemption from ERISA thereby giving him or his heirs the right to sue for bad faith), the (legal) action was exempt from ERISA.

The jury found that Aetna acted with malice, oppression, and fraud in the handling of David Goodrich's treatment requests, and in the first phase of the trial awarded $747,655.88 for the unpaid medical bills, and $3,790,603.52 on the wrongful death cause of action. (FREE has noted the glaring absence of statistics that would document the thousands of people killed, disabled and financially damaged over the last decade by being fraudulently denied essential and timely health care services and financial compensation by certain insurance companies). In the second phase of the trial, the jury awarded $116,026,104.00 in punitive damages, for a total verdict of $120,546,363.40.

"The Judge denied Aetna's motion for a new trial and JNOV, and the verdict was left intact, in it's entirety. In it's decision not to reduce the punitive damage reward, the court noted, among other things, the following:

" In arriving at this determination, and recognizing the purpose of punitive damages to punish and deter, this court also considers the fact that Aetna Services, Inc., and Aetna US Healthcare of California, Inc., are both generally immune from civil suits arising out of the provision of managed health care, based upon the provisions of ERISA. (In other words, you and I can be killed or damaged by the insurance provider and it's too bad for you and your loved ones... no recourse under the law) The Goodrich claim is a rare exception. Additionally, managed health care providers have significant contact with the general public and the general public is more dependent upon the managed health care providers than virtually any other product or service industry in the private sector"

SUMMARY:

The big difference between you, I, and Mr. Goodrich is that Mr. Goodrich or his heirs always had the right to sue their insurance provider for malpractice, bad faith and wrongful death. The rest of us 125 million citizens covered under a managed health care program are prohibited by the Federal ERISA ACT from bringing our case to a jury for this type of maltreatment by an insurance company managed health care provider; an HMO, POS, PIP or PPO. All of us everyday folk are prohibited from bringing to a jury the type of bad faith and wrongful death lawsuit that was filed on behalf of the widow of David Goodrich.

Whether you have a car accident, work or off-work injury or an illness, your claim for injury or illness most likely falls under the jurisdiction of one of these managed health care plans. The insurance claims adjusters can let you or a loved one die waiting for approval of health care services, an approval that can be delayed for weeks or even months.... or never come at all. Just go to your local hospital emergency room and find out how many people have died or experienced extreme complications in their injury or illness caused by the delay from waiting for approval by an insurance claims adjustor. Some doctors in hospitals will not operate on you if you are covered under certain insurance company health care programs because they know they will not get paid or will experience a year or more of delay in getting payment... or partial payment.

The health care insurance industry has killed more people than Al Capone ever did with a machine gun. Isn't it time to remove the insurance industry and the HMO clerks from the life and death and quality of life decisions over your life? Why not have Hospital or Physician run managed health care programs covering injury and illness and eliminate the multi-trillion dollar insurance industry with it's 40% to 200% profit margins

At F.R.E.E., the insurance industry is not the only model we have put under our microscope. We intend to look at several different models (the media; politics; big business as a whole; the concept of commercialism and more) and have conversations with as many of the everyday folks that keep this great country working. In this way, we hope to find the answers that will meet peoples' needs. We are not interested in agendas. We are interested in people! That is where our hearts are. We want to make a difference in this country. We want to teach others how to do the same.