A recently-filed class action accuses MetLife of using a software program to improperly deny insurance claims. The complaint charges that MetLife uses computer 'fee-review' software -- known as 'Decision Point' -- to improperly limit and exclude from coverage part of Plaintiff's and the Class's reasonable medical expenses incurred after a covered occurrence.
The suit says that MetLife uses Decision Point to justify its denial of claims without first deciding whether those claims are reasonable. Indeed, according to the complaint, Decision Point software is not designed to determine whether a charge is 'reasonable' or 'unreasonable,' though MetLife uses it for this very purpose.
Rather, the software is simply intended to determine what percentage of the customer's costs are covered by comparing those costs with a set benchmark figure.
According to the complaint, [i]nsurers such as Met select a particular 'percentile' payment benchmark and any amount of the charge that exceeds that payment benchmark is capped and excluded from coverage. Further, Decision Point software does not (and cannot) analyze in any way whether a submitted charge incurred by its insured is higher [or] lower than the usual and customary charge for the medical services rendered.
The suit contends that MetLife's use of Decision Point to deny claims constitutes a breach of contract, since the company does not determine, as the policy requires it to do, whether any submitted medical payments claim is reasonable. Moreover, Met's Policy does not define 'reasonable' expenses, or for that matter, what constitutes 'unreasonable' expenses. For every medical payment benefit reduced with [Decision Point], Met simply reduces the benefits based upon predetermined and undisclosed limitations of its own selection.
The lead plaintiff in the suit is Back Doctors LTD, a medical office in Swansea, Illinois, led by Dr. Kathleen Roche. According to the suit, Roche treated patients who were injured in covered occurrences, and charged usual and customary fees for her service. When she submitted the claims to MetLife, however, the insurer excluded part of her charges based on an undisclosed fee review algorithm.
Additionally, the suit claims that MetLife is unable to vouch for the accuracy of the Decision Point software, which is licensed by Ingenix, a third party corporation owned by managed health care conglomerate United Healthcare Corporation.
According to the complaint, MetLife is unable to substantiate the accuracy or propriety of its fee review determination or verify the components of the algorithm used to purportedly make 'reasonable' or 'unreasonable' determinations, and has never inquired whether fee review based coverage limitation and Policy exclusion determinations are consistent with Policy requirements and definitions.
The suit contends that MetLife saved untold dollars on claims that it should have paid under the express terms of the policy. In addition to the breach of contract claim, the suit charges MetLife with violation of the Illinois Consumer Fraud Act.