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To Really Deny Claims, You Need Computers

BELLEVILLE, Ill. (CN) - MetLife uses a software program to deny claims that should be covered, a class action claims in St. Clair County Court. Lead plaintiff Back Doctors claims MetLife uses its Decision Point software to routinely deny coverage.

"Decision Point software is not designed in the first instance to determine whether a charge is 'reasonable' or 'unreasonable,' though MetLife uses it for this very purpose," the complaint states.

Back Doctors claims the software simply compares the line-item charge billed for a medical procedure to internal fee schedules imbedded within the software. MetLife then selects a percentage payment benchmark and any amount of charge that exceeds the mark is automatically excluded from coverage, the complaint states. Back Doctors says MetLife doesn't disclose the benchmark and does not take into account what would be a reasonable charge for services.

"Decision Point software does not (and cannot) analyze in any way whether a submitted charge incurred by its insured is higher/lower than the usual and customary charge for the medical services rendered because the software does not individually investigate whether a particular charge is reasonable, unreasonable and/or 'usual and customary,' as required under the Policy," the complaint states. (Parentheses in complaint.)

"Simply put, Decision Point software does not even make these determinations. Accordingly, Met's conduct constitutes a breach of contract under the policy."

The class consists of all covered claimants under a MetLife policy who received a benefit less than the submitted line-item expense pursuant to the software benchmark. The class seeks damages for violations of the Illinois Consumer Fraud Act and is represented by Brian Kreisler of Becker, Paulson, Hoerner.

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