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rosco 357


Veteran
Originally published 04:45 a.m., October 14, 2009, updated 11:46 a.m., October 14, 2009
Insurer ends health program rather than pay out big

William Ehart
http://washingtontimes.com/news/2009/oct/14/ny-insurance-company-tries-to-rid-itself-of-high-c//print/

Ian Pearl has fought for his life every day of his 37 years. Confined to a wheelchair and hooked to a breathing tube, the muscular dystrophy victim refuses to give up.

But his insurance company already has.

Legally barred from discriminating against individuals who submit large claims, the New York-based insurer simply canceled lines of coverage altogether in entire states to avoid paying high-cost claims like Mr. Pearl's.

In an e-mail, one Guardian Life Insurance Co. executive called high-cost patients such as Mr. Pearl "dogs" that the company could "get rid of."

A federal court quickly ruled that the company's actions were legal, so on Dec. 1, barring an order by the federal Department of Health and Human Services, Mr. Pearl will lose his benefits.

His medical treatment costs $1 million a year.

Most of that is for 'round the clock, in-home nursing care - for operation of his ventilator, hourly breathing treatments and continuous intravenous medication.

(Corrected paragraph:) A Guardian spokesman said policies such as Mr. Pearl's - which offered unlimited home nursing - had simply become too expensive for new small-business customers to buy, and that even Medicaid and Medicare do not cover 24-hour home nursing. His parents, Warren and Susan Pearl of Fort Lauderdale, Fla., said their health insurance premiums had risen over the years to $3,700 a month.

As a last resort, Mr. Pearl would be admitted to a state hospital under Medicaid. But the Pearls consider that a death sentence.

"Ian would be lucky, or unlucky, to survive more than a matter of weeks or months," Mrs. Pearl said. "One-on-one skilled nursing is essential."

Her husband, 60, a wealthy businessman, said the couple have enough savings to pay for their son's care for a few years, and after that, they could mortgage the family's home.

The Pearls' younger son, Matthew, is the best-selling author of "The Last Dickens," a novel published this year by Random House.

"Ian and Matt spend hours on the phone discussing story lines. Matt uses Ian to bounce ideas off of," Mrs. Pearl said.

Ian Pearl became the first wheelchair-bound pupil to be mainstreamed in the Broward County elementary schools, and he was elected president of his high school class at University School of Nova Southeastern University in Fort Lauderdale.

He has Type II spinal muscular atrophy - which often kills victims in infancy. He grew to adulthood only to suffer respiratory arrest at 19. He has required a tracheal tube ever since.

He has been fortunate most of his life to be covered under the Guardian small-business health plan his father bought through his remodeling company, Warren Pearl Construction of New York City.

Generous by modern standards, the health insurance plan covered home nursing, something most small-business plans do not cover today.

Over the years, Guardian has scaled back the benefits in new types of plans it has offered, to the point where it no longer offers in-home nursing coverage.

In the state of New York, where Mr. Pearl's business operates, 54 other employers offered the Guardian plan. Their policies covered nearly 500 employees and dependents, including two other severely ill people.

The Pearls moved to Fort Lauderdale 30 years ago because the humidity there is beneficial to their son. Warren Pearl has commuted back and forth from New York every weekend since.

He said Guardian has for years used private investigators to find pretexts to deny coverage. An investigator came to their door, he said, to get proof that he does in fact fly back and forth to New York and that his two-employee company really operates in New York. Investigators went to Mr. Pearl's job sites.

"The insurance companies are cheating in order to have obscene profits," he said.

Guardian, a 150-year-old mutual company, reported profits of $437 million last year, a 50 percent increase over $292 million in 2007. It paid dividends of $723 million to policyholders and had $4.3 billion in capital reserves, according to its annual report. The company's investment income totaled $1.5 billion that year, a small increase from the year earlier.

The insurer also canceled similar policies in New Jersey and South Carolina, and earlier ceased offering any health plans in Colorado, but did not cancel all of the policies in every state in which they were offered, said John Fried, the Pearls' attorney. The company took the action only against those plans where claims were highest, he said.

The insurer discontinued the coverage late last year, but was required by law to continue paying for Ian Pearl's care for another year.

In 2006, Guardian began an initiative called Moving Forward, which was "designed to increase Guardian's competitive position by reducing what it paid out in claims," wrote Judge William Pauley, of the U.S. District Court for the Southern District of New York, in his summary judgment in Guardian's favor in July.

The move would help the company lower overall rates to compete better for more business.

The judge found that the company had not violated the Employee Retirement Income Security Act (ERISA), because it canceled entire policy lines. The Pearls also claimed Guardian violated the Health Insurance Portability and Accountability Act (HIPAA), but the judge found that only HHS can enforce that law and that private citizens cannot sue under it.

The Pearls appealed to HHS under the Bush administration and were told the agency could do nothing, Warren Pearl said.

They petitioned again in a letter to HHS Secretary Kathleen Sebelius on Oct. 5, with support from their congresswoman, Rep. Debbie Wasserman Schultz, Florida Democrat, but have not heard back.

Contacted by The Washington Times last week, the agency said, "Our Department has been contacted by the Pearl family and we have heard their very serious concerns. We are actively investigating this matter."

The House Energy and Commerce Committee, chaired by Rep. Henry A. Waxman, California Democrat, is also investigating, the Pearls said. The committee held hearings on benefit cancellations earlier this year.

Spokesmen for Mr. Waxman and Ms. Wasserman Schultz did not respond to requests for comment.

In an e-mail to four other Guardian executives entered into evidence in the Pearls' suit, company Vice President Tim Birely discussed how the company could "eliminate this entire block to get rid of the few dogs."

He concluded, "Paul [Saylor], keep in mind that my intent is to be as narrow and laser-like as possible. We may need to broaden some things in NY due to state of domicile and some historical [nonsense] with some of these policyholders."

Asked about the use of the phrases such as "get rid of" and "dogs," Guardian spokesman Richard Jones said, "I'm not aware of any language related to any of the things that you just mentioned, no."

He said plans such as Mr. Pearl's had simply become too expensive to market to employers.

"We certainly sympathize with [Mr. Pearl's]'s condition. As a business, though, we have to offer plans that enough customers want," Mr. Jones said.

"But in this particular case the expense of the plan meant that most small businesses were not able or were not willing to purchase it. As a result we started offering different plans," he said.

"This has been through the courts. Guardian's activities were upheld by the courts as well as by the New York State Department of Insurance.

"We certainly don't think this particular case has anything to do with health care reform," Mr. Jones said.

Mr. Fried argues in his appeal that Judge Pauley misinterpreted the ERISA law.

"I think we're entitled to a trial as to whether Guardian's discontinuation of its policy was in effect discrimination against Ian Pearl," he said.

The Pearls say they are out for justice.

"This is a matter of life and death for my son," Warren Pearl said. "I have to have faith that HHS will enforce the law.

"This is attempted murder, as far as I'm concerned. They targeted us, they never expected to get caught. I believe that justice will prevail."

gypsy


Moderator
This is a matter of life and death for my son," Warren Pearl said. "I have to have faith that HHS will enforce the law.

"This is attempted murder, as far as I'm concerned. They targeted us, they never expected to get caught. I believe that justice will prevail."

Yes I agree,. Another example we need health care reform get rid of the big mafia insurance companies..

SSC


Admin
This is the first in a long line of companies opting out before Obama lowers the hatchet..We dealt with Ins. companies after Katrina, State Farm and Alstate should be burned at the stake.. The annointed one is ignoring the screwing we are getting from them and the Fed. flood plan...Bunch of bullshit, but you will see this more and more..

gypsy


Moderator
I saw a good News broadcast of the people who trust obama, to help them,of course it will cost more money
.Plus he will come down hard on insurance companies who may have broke the law, by not paying people 's policies/most understand the full plate inherited and time it will take to correct it all~

SSC


Admin
Seems like 10 months into this fiasco, Obama would have cleared away most loose ends, all Presidents inherited issues from previous administrations ..comes with the job. Obama made tons of promises, expensive ones which will drown us in debt for years and years. Not much of a showing so far..just spending and purposed spending...Where is the milk and honey he promised ?? People are getting tired of his bullshit promises, time for decisive action..

gypsy


Moderator
Eight years to cause this fiasco, plus the years repubs controlled house/senate almost destroyed this great nation Now we have some one who is rebuilding~ plus we were already drowned in debt/I :applaus:Obama an Pray he succeeds for you an me~ an this Country~~ Amen!
I guess your starting your obsession war with me again~
not very good at keeping your word~ Well carry on, because I won't, this is my last response to you~~ Another Amen~

You Go Obama!

runawayhorses


Owner
Take a deep breath.... exhale and relax. Actually, if you could intervene the "deep breath" with a joint that would even be better..

In all seriousness, relax, you can have good debates with SSC, just TRY to be reasonable and make your points clear. Thats all anyone can do in any discussion.

That's my 2 cents, I knows its worth 1, but whatever...

gypsy


Moderator
Thanks Tyler.
Lawdy,I only tried a joint once LOL but I figured it isn't for me.
my posts are as reasonable as anyones.I think .
She can't debate she gets angry ,an name calls.
I have tried, so I will walk away~
plus whatever we say,or debate won't change a thing,. they are all opinions..

SSC


Admin
She has a name ..SSC..she is relieved no more PM's will be flooding my mailbox..good move GYP..flood me with useless dribble PM's then put me on ignore...LMAO@U...

gypsy


Moderator
two hours ago I sent a pm to this person,I was ignoring her. ,this is all I can see of the response she keeps replying to me here on board







This post was made by SSC who is currently on your ignore list. Display this post.

11 Stop the PM's you have me ignored...lol on Fri Oct 16, 2009 8:56 pm

SSC


Admin
What a fucking idiot..put me on ignore then flood me with PM's I can't respond to....LOL

rosco 357


Veteran
well back to the insurance company, i understand it cost alot, to keep this person alive, but to me a deal is a deal, but what pisses me off is they dropped him for 1 million a year and removed whole lines of coverage, so others will loose things also,BUT i will paste the part that pisses me offf, like it said this nursing acare and other thing cost 1 million a year, for this person, so here is the paste that pisses me off . if it was breaking the company i might understand ,but

Guardian, a 150-year-old mutual company, reported profits of $437 million last year, a 50 percent increase over $292 million in 2007. It paid dividends of $723 million to policyholders and had $4.3 billion in capital reserves, according to its annual report. The company's investment income totaled $1.5 billion that year, a small increase from the year earlier.

reading this makes me want to vomit, so i guess not covering this guy their profits would be just under 438 million since i think his premiums were 3700.00 a month,

gypsy


Moderator
I totally agree, that makes me angry also, this type of thing should be stopped..
hopefully it will.

SSC


Admin
With Obama opening a can of worms with the ins. companies watch and see what happens. No different than StateFarm dropping paid up policies in Florida and the gulf coast, they can and did drop home owners ins. as did Alstate. This is just the beginning..

rosco 357


Veteran
SSC wrote:With Obama opening a can of worms with the ins. companies watch and see what happens. No different than StateFarm dropping paid up policies in Florida and the gulf coast, they can and did drop home owners ins. as did Alstate. This is just the beginning..

i think this decision would have been made by this company no matter who was the president,, besides if anything passes it will have to accept preexisting conditions or it will not work and i think all the bills have that in them, , and i would imagine for much less than
3700.00 a month, but we shall see, it will get interesting, private policys u just cant trust, i think this one was not that, if i remember the article his dad had employees on it, but i may be wrong,thats why removed lines of coverage, anyway i have said this and it has nothing to do with obama but my brother in law has a private policy and when he had cancer and had the operation, they doubled his premiums, but private policys are tough and basically are like car insurance , if u get to may tickets or wrecks u get canceled,
i have always been in a big group insurance so i have not experienced that, my sister had a better policy but they would not accept him after the cancer,

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