The Houston Chronicle recently ran an article about insurance company USAA’s practice of submitting claimants’ medical bills to be reviewed by a company in Alabama. That company is supposedly independent, but of course the Reviewing company knows that if it doesn’t produce the results wanted by USAA it will no longer receive business from the insurance carrier.
Our firm has seen this tactic used by USAA and by other insurance companies to dispute perfectly reasonable medical and hospital bills, forcing our clients to file suit in order to receive fair compensation. USAA uses this tactic against their own policyholders who have Personal Injury Protection coverage. Here are excerpts from the newspaper article:
USAA again is defending itself against charges it utilizes a “cost containment program” to improperly reduce or deny medical payouts to insurance customers injured in auto accidents.
The latest claims against the San Antonio financial and insurance company were made in a federal lawsuit filed this week in Oregon.
The lawsuit, which seeks national class-action certification, charges that USAA uses an outside auditor to assess claims and to “uniformly conclude that medical treatment was not needed.”
USAA denies the allegations.
USAA previously settled two class-action lawsuits that accused it of using flawed data to arbitrarily deny a portion of the medical benefits for injured customers who have personal-injury protection (PIP) or other medical-payments coverage on their USAA auto-insurance policies.
One of those cases, filed in Arizona, was settled last summer. Claims are still being processed, so the amount to be paid out under the settlement hasn’t been determined.
The other case, filed in Illinois was settled in 2005. Lawyers for the plaintiffs valued the settlement on their website at $35 million, a figure USAA spokesman Paul Berry called “probably wildly” inflated.
USAA settled the two cases because it was the “right thing to do for our membership,” Berry said. He noted both courts endorsed USAA’s bill-review practices.
“We pay all reasonable, necessary and accident-related bills,” Berry said. “That doesn’t mean we pay all bills. If you had injuries or you received some treatment that had nothing to do with (an auto) accident, we’re not going to pay those bills.”
USAA relies on Alabama-based Auto Injury Solutions to help review medical bills to determine whether they are reasonable and necessary and to weed out duplicative and fraudulent claims. Bills deemed suspicious are reviewed by a doctor or other health-care professional, Berry said. Even when one of its doctors concludes the medical care wasn’t necessary, the bill still goes through several other reviews, he said.
In the latest Oregon lawsuit, four unrelated USAA customers in separate accidents allege the medical reviews were a “sham.”