Health Care Plan Provider’s Conspiracy / Scheme to Underpay Insurance Claims Submitted by Providers and Beneficiaries Not “Errors or Omissions” and Reinsurance Policies Covering Professional Liability Policies Not Implicated

Posted on by Carson J Tucker, JD MSEL

Reinsurers Not Responsible for Coverage of Claims Against Medical Insurance Claims Service Brought Under Conspiracy Theory Pursuant to RICO

Amicus Curious

In June, a Court of Appeals panel in Indiana issued an unpublished, and therefore, non-binding, opinion speaking to an issue that has significant relevance for several of our insurer and employer clients, and third-party claims administrators with whom we work.

The insurance coverage case, Wellpoint, Inc., et al. v. National Union Fire Ins. Co., et al, arose out of allegations in the underlying lawsuits that a network of health insurance companies, Wellpoint, Inc. and Wellpoint Health Networks, Inc., eventually merged into Anthem (hereafter referred to simply as Wellpoint unless otherwise indicated), conspired with other health insurance companies to deny medical providers’ and doctors’ claims for reimbursement of health care services.

The Underlying Lawsuits – The Alleged Conspiracy 

The plaintiffs in the first underlying suit were members of a health plan issued by Wellpoint, which permitted beneficiaries to use the services of out-of-network providers.  The plaintiffs filed an action in Connecticut…

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Published by Carson J Tucker, JD MSEL

Owner of law firm since July 2014; Handles all types of appellate matters and assists other lawyers with complex litigation and insurance coverage issues; Admitted to the Supreme Court of the United States, the Sixth Circuit Court of Appeals and the State Bar of Michigan; Expertise in prosecuting and defending appeals with several significant successes in the Sixth Circuit Court of Appeals, the Michigan Supreme Court and the Michigan Court of Appeals; Author of briefs amicus curiae in the Michigan Supreme Court for the Michigan Defense Trial Counsel and the Insurance Institute of Michigan; Represents Insurance Companies, Major International Business, Governmental Entities, Law Enforcement Officers and County Sheriffs. Board of Directors, Michigan Defense Trial Counsel Amicus Committee Co-Chair, Michigan Defense Trial Counsel Military - Retired Major in the Judge Advocate General (JAG) Corps of the United States Army, Brigade Judge Advocate and Staff JAG officer for the Maneuver Training Center, Camp Grayling, Michigan; Recipient of the Army's Meritorious Service Medal (the highest medal of honor available to Soldiers serving in non-combat roles); 2012 Graduate of the Judge Advocate Officer Advanced Course, at The Judge Advocate Legal Center and School, Charlottesville, Virginia. United States Navy Reserves, Combat Warfare Qualification, January 1989 to July 2003 Former law clerk to Justice Stephen J. Markman, Michigan Supreme Court, Research Attorney, Michigan Court of Appeals. Insurance Coverage Associate Plunkett Cooney; Environmental Law Attorney at Squire Sanders, now Squire Patton Boggs; Master's Degree in Environmental Law; Environmental Law Scholar, ALI/ABA Washington, D.C., Juris Doctorate, Vermont Law School, Environmental Editor, Vermont Law Review; Treasurer and Finalist, Moot Court Advisory Board.

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