Ambetter Lawsuit: As an Overview

August 16, 2021 by Lewis
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Family Physician sued for refusing to Accept HMO Medication From Lawsuit Settlement

The first phase of the Ambetter lawsuit is that the legal team representing the plaintiffs, headed by John Guedes, will argue that the insurance company, Ambetter, intentionally mis-sold Ambetter policies to clients who were not in need of the health plans. In this phase, the legal team will attempt to convince the jury that the defendants, namely Ambetter, engaged in a conspiracy with the insurance providers to mis-sell the medical plans. One of the main arguments made by the plaintiffs and their lawyers will be that the defendant, or his agents, did not want to advertise the health plan to potential clients but instead, they conspired with other insurance agents to sell the plans without advertising the plan to potential clients. Other plaintiffs in the lawsuit are similarly positioned, however, with claims that the defendants did not tell them that the insurance plan was available, thus allowing them to enroll without providing a reason why. For these plaintiffs, their attorneys will attempt to show that, in all likelihood, the defendants intended to defraud the plaintiffs as part of their campaign to run the health system.

The second phase of the lawsuit, which the insurance companies will counter, is that the defendants did not intend to sell the medical plan at all. For the insurance companies, this argument goes far beyond what the company wants. For starters, it assumes that plaintiffs actually intended on purchasing the health insurance, and that the plaintiffs were duped into signing on with the defendants when they received a letter from the peach state, stating that they qualified for the insurance plan. Furthermore, plaintiffs accept this argument because of the defendants’ “bait” of low premiums, despite the fact that the “bait” came only after the plaintiff’s attorney requested the companies to conduct a health insurance review cheap rates. The problem with this argument, as stated by John Guedes, one of the attorneys for the plaintiffs, is that the companies have a duty to conduct a health insurance review cheap rates, and they failed to do so.

To rebut the claim that the companies breach their duty, plaintiffs’ attorneys are asking the court to allow them to present evidence to the insurance companies showing that defendants violated their duty of care when selling the HMO health plans in Indiana. To do so would allow the plaintiffs’ attorneys to argue that the defendant doctors sold a product that was defective and injurious, and that the doctors violated the duty of care owed to the plaintiffs. In addition, the court could rule that the doctors abused their duty of care when allowing the HMO health plans into the state statute, even though the HMO itself did not sell the plans themselves.

Doctors and health insurance providers in Indiana agree with plaintiffs that it would be difficult for them to accept Ambetter lawsuit settlements. The doctor groups claim that it will be very difficult to change the way doctors work. Further, physicians feel that the settlement deals are unfair and unjustifiably risky for both doctors and their employers. As one doctor put it, if the state can accept Ambetter lawsuit settlements, why would it be hard for physicians to receive lower health insurance rates? Similarly, plaintiffs’ attorneys would argue that doctors do not have a choice but to accept lower healthcare rates.

If the State of Indiana agrees with plaintiffs and allows insurers to reject certain medical treatments, such as those accepted by independent or coordinated care settings, such as in an inpatient hospital, the result could be disastrous. Many hospitals, doctors, and patients in the Hoosier State believe that the rules governing coordinated care are too restrictive and unworkable. Therefore, if the State of Indiana were to adopt rules similar to those adopted in the European Union, doctors might be forced to accept treatment from any provider today who offers it, regardless of its quality. This scenario could create chaotic situations where a patient is subjected to a lack of access to essential healthcare.

If the State of Indiana were to adopt rules similar to those adopted in the European Union, the result would be disastrous for the state’s health system. Instead of allowing health care providers to decide whether they accept the treatments provided by independent or coordinated care settings, the State of Indiana should have the power to ban practices that violate the provisions of its tort law. The sensible solution would be for the State of Indiana to eliminate its requirement that its family physicians and other healthcare providers accept “any” provider, regardless of its ability to provide the services required by the individual.

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