Matthew A.S. Esworthy, a partner at Shapiro Sher Guinot & Sandler, was one of ten elected and appointed alumni to a serve a three year term – beginning on July 1, 2016 through June 30, 2019 –  with the Penn State Alumni Association’s
Governing body, Alumni Council.  Mr. Esworthy was selected and appointed
by the Association President Kevin R. Steele.  The Penn State Alumni
Association is the largest dues-paying organization of its kind in the world,
with members in every state in the U.S. and numerous countries.

Mr. Esworthy also serves as President of the Penn State Law School Alumni Association. During his tenure, he has worked to strengthen ties between law school alumni across the country, and to enhance the professional development of the next generation of young attorneys. In his legal practice, Mr. Esworthy represents clients in civil and criminal litigation, including white-collar criminal cases and complex commercial disputes.

Shapiro Sher Guinot & Sandler was founded in 1972 by Ronald M. Shapiro, with the mission of providing outstanding legal counsel for Maryland businesses of all sizes. Since then, Shapiro Sher has grown into a full-service, nationally-recognized firm that for the past four years has been named Top Mid-sized Law Firm in Maryland for Business and Transactions by Super Lawyers®, a division of Thomson Reuters. The Firm includes practices in litigation, corporate, real estate, employment, sports, banking & finance, and bankruptcy & creditor’s rights. For more information, please visit the Firm’s website at www.ShapiroSher.com.

April 13, 2016

Meet Sandler’s Newest Client – Al Capone

Mr. Sandler provided the original script and participated in the production of “The Trial of Al Capone” presented at The Goodman Theatre in Chicago by the ABA Section of Litigation.  Mr. Sandler played the role of defense counsel for Al Capone played by Bob Clifford.  The event was covered by several media outlets, including CBS Chicago,  WGN TV, and the Chicago Daily Law Bulletin.  See Scrapbook. 

BY ALEX J. BROWN 

While our politicians debate the merits of the Affordable Care Act (a.k.a. “Obamacare”), insurers continue to deny health insurance claims by the thousands every year. These denials often saddle consumers with outsized medical debts they cannot afford. 

As a former Senior Counsel to the Maryland Insurance Administration and now an attorney in private practice, I have been receiving an increasing number of calls from individuals facing personal financial crises caused by health insurance claim denials. Unfortunately, there is a real difference between obtaining a health insurance policy and forcing the insurer to provide coverage when you need it most. 

Large claim denials can devastate a family’s finances and add to the stress caused by serious illness or injury.  Some of my clients have been stuck with six-figure medical bills and forced to fight their insurance company even while struggling to regain their health.  Fortunately, when insurance claims are improperly denied, policy holders do have options. They can often force their insurers to reverse their initial denials and provide coverage. 

A case in point: I recently convinced BlueCross BlueShield of Maryland to withdraw voluntarily a denial of coverage for a $160,000 microprocessor-controlled “Genium” prosthetic knee.  My client had been in a terrible automobile-related accident and had lost one of his legs.  The client works for a veterinarian, and his job requires him to lift and handle large dogs, often weighing more than one hundred pounds.  The client also lives at the top of a hill and cuts wood to heat the family home.  

My client tried the ordinary prosthetic knee that BlueCross BlueShield agreed to pay for, but the knee wasn’t functional.  It would lock when my client was lifting large dogs, and during attempts to travel to and from the family home.  After multiple falls, including a fracture and dislocation of the left shoulder, my client switched to the special, microprocessor controlled “Genium” knee, which helped my client move better and avoid falls. With the Genium Knee, the client could perform work duties, and travel to and from home, without assistance and without falling. Problem solved – that is, until BlueCross BlueShield of Maryland created a new one. 

BlueCross BlueShield denied coverage for the Genium knee because it was allegedly not “medically necessary.”  As strange as it sounds, the insurer’s position was that it was not “medically necessary” for the client to have a knee that allowed performance of work duties and safe travel to and from home.  

When my client appealed this denial, BlueCross BlueShield obtained a “peer review” opinion from a doctor who confirmed the denial, despite a contrary opinion from the client’s treating doctor at Johns Hopkins.  In my experience, these “peer reviews” seem to be nothing more than superficial rubber stamps of the health insurer’s position. 

In this case, as in others, the peer-reviewing doctor was anonymous.  The doctor had never treated my client, and in fact worked for a company that BlueCross BlueShield hires to conduct peer reviews.  Not surprisingly, the doctor listed “CareFirst BCBS” as his/her “client” on the “peer review” form – not the patient.  The doctor simply stated a superficial conclusion that was advantageous to the health insurer.  

The contrary opinion of the treating Johns Hopkins doctor apparently made no difference.  This practice of using non-treating, anonymous “peer reviewers” to confirm denials of health claims is not limited to BlueCross Blue Shield.  

I am currently involved in a different case where United Healthcare Insurance Company similarly retained an anonymous, non-treating “peer reviewer” to rubber stamp its denial, despite the fact that he/she had never even met or talked to my client, and despite contrary opinions from actual treating doctors.  In my view, these “peer reviews” are worthless, and do not provide a valid basis for a health insurer to “confirm” the denial of a claim. 

In my Genium knee case, my client filed a complaint with the Maryland Insurance Administration, and then hired me to assist.  I drafted a detailed letter to the Administration explaining the deficiencies in BlueCross BlueShield’s analysis, and in the superficial “confirmation” of the anonymous peer reviewer.  After receipt of my letter, BlueCross BlueShield of Maryland simply withdrew its denial, and agreed to pay for the $160,000 Genium knee.  

While I am pleased for my client, his “victory” came at a cost. Doing battle against insurance companies can be time-consuming and draining. In addition, the Maryland Insurance Administration did not force the insurer to pay attorney fees. My client paid that cost only in the face of less appealing alternatives: pay a $160,000 bill for the knee out of pocket, or revert back to the unworkable knee.  

Sadly, nothing about this case incentivizes BlueCross BlueShield to pay valid claims promptly in the future.  In fact, the current system provides financial disincentives to health insurers to paying large claims.  If my client had not had the resources to pay my bills, BlueCross BlueShield may have “saved” $160,000.  

If the individual fights back, as my client did, the insurer can just honor its contractual obligation to pay the claim, as BlueCross BlueShield agreed to do.  There is no financial penalty under the statutes to the insurer for forcing my client to file an appeal, then an administrative complaint, and then hiring an attorney to argue for coverage.  BlueCross BlueShield simply folded its tent, paid the claim, and the Administration closed its file.  

The Maryland General Assembly could help fix this problem by passing a statute that truly penalizes insurers who deny valid claims. In the meantime, if you are facing similar issues, and would like assistance in addressing your insurance questions, or in reviewing your current coverage, feel free to contact me, Alex J. Brown, at Shapiro Sher Guinot & Sandler, P.A. and Chairman of the firm’s Insurance Practice Group, at 410-385-4220, or by email at ajb@shapirosher.com.

Eric R. Harlan and Renée Lane-Kunz gave an employment law seminar for the Association of Legal Administrators, Maryland Chapter.