Insurance company sued for canceling after woman's costly surgery

Kelly Holleran Aug. 26, 2009, 1:55am

A Madison County man has filed suit against his former insurance provider, alleging his insurance was canceled after his wife's costly surgery.

Dale Werner claims he was insured by Group Health Plan, Inc., a Coventry Health Care Plan, when his wife, who was also insured through his plan, sought pre-certification for a medical procedure she intended to have performed in August 2008.

In July 2008, at the same time Werner's wife was seeking pre-certification, Werner called Group Health Plan to inquire about his premium payment, according to the complaint filed Aug. 19 in Madison County Circuit Court.

Group Health Plan both approved Werner's wife's pre-certification and told Werner that he had no premium due and, in fact, had a credit balance in his favor, the suit states.

"Based upon said reliance, Plaintiff's wife underwent a costly pre-certified medical procedure in or about August 2008," the complaint says.

But after the surgery, Group Health Plan canceled Werner's insurance on the basis of Werner's alleged non-payment of which he was unaware. It refused to reinstate the policy, plus refused to pay the remaining outstanding medical claims for services rendered on Werner's wife, he claims.

In addition, Group Health Plan asked Warner to pay for bills it had already paid following his wife's procedure, according to the complaint.

"Defendant, Group Health Plan, Inc., A Coventry Health Care Plan's promises and statements to Plaintiff were made in bad faith with the express intention of inducing Plaintiff and/or his wife and/or dependants to engage in costly medical services in reliance of said promises and statements, knowing that Defendant would later deny coverage for the costs of those services," the suit states.

"Upon information and belief, the Plaintiff states that the statements made by Defendant, Group Health Plan, Inc., A Coventry Health Care Plan's agents and/or employees were made with the intent to induce the Plaintiff to not make further payment on his premiums while lulling Plaintiff into a false sense of security with respect to obtaining more costly medical procedures."

Because of Group Health Plan's actions, Werner claims his credit scoring has been degraded, which may affect his future ability to obtain credit, and he incurred costs and expenses related to missed days from work, telephone calls and legal costs.

In the seven-count suit, Werner is seeking a judgment of more than $300,000, plus attorneys' fees, costs and other relief the court deems just.

Donald J. Ohl and Stephanie M. Galetti of Knapp, Ohl, Green and Marron in Edwardsville will be representing him.

Madison County Circuit Court case number: 09-L-868.

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