Gray·Duffy Secures Reinstatement of Wrongfully Denied Insurance Benefits

March 2011

Overview

John Duffy of Gray·Duffy’s Encino office obtained a reinstatement of a client’s health insurance benefits after they were wrongfully denied by the insurance company. The private insurance company questioned the client’s application responses and threatened to cancel the insurance subsequent to a claim being filed.

Discussion

Jill Plotkin v. Blue Shield of California

The firm’s client, Jill Plotkin, applied to Blue Shield Health Plan for individual/family health coverage. During the application process, the agent completed the application and had the client sign the application. Ms. Plotkin disclosed a prior visit to a hospital emergency room to have her blood pressure checked. The agent informed Ms. Poltkin there was no need to reference the ER visit in the application since she was not seeing a doctor or receiving any treatment for high blood pressure.

Subsequent to receiving notice that the insurance was in effect, Ms. Plotkin went to a doctor for a checkup, which revealed a serious medical condition requiring treatment.

Blue Shield initially paid the medical bills; however, as the bills began mounting, Blue Shield conducted an investigation and issued a denial stating that Ms. Plotkin did not provide complete and accurate information on her application for health coverage.

Mr. Duffy challenged the denial of coverage by demonstrating that Blue Shield did not specifically ask for the information upon which they were basing their denial and it was the provider’s duty to ask for the information it felt was necessary to evaluate a client’s application. Through a series of specific questions posed by Blue Shield regarding Ms. Plotkin’s prior medical history, medical tests and doctor visits subsequent to the emergency room visit, Blue Shield was forced to withdraw the denial after realizing its refusal of health insurance coverage was without merit.

Please Note: This article is necessarily general in nature and is not a substitute for legal advice with respect to any particular case. Readers should consult with an attorney before taking any action affecting their interests.