A man who was transferred to Barnes Jewish Hospital via air ambulance for a life-saving heart surgery is suing his health insurance for refusing to cover the cost of his transport.
John Keller filed the complaint May 27 in the U.S. District Court for the Southern District of Illinois against UnitedHealthcare Insurance Company of Illinois, alleging breach of statutory, contractual and fiduciary obligations and violations of the Employee Retirement Income Security Act of 1974.
According to the complaint, Keller claims he suffered a life-threatening heart attack while golfing near Paducah, Ken., on May 28, 2017. Keller was transported to Lourdes Hospital where he came under the care of Dr. Joel Talley.
The following day, it was determined that Keller had 80 percent stenosis in his middle cerebral artery, 100 percent stenosis in his anomalous coronary artery, and 90 percent and 100 percent stenosis in his left and right carotid arteries. As a result, Keller was in need of a heart bypass.
He alleges Talley “felt that Mr. Keller was close to death” and determined the local hospitals in the Paducah region were insufficient to provide the level of care Keller’s condition required. Talley’s medical opinion was that Barnes Jewish Hospital in St. Louis was the closest facility that could provide adequate care and believed it was medically necessary to transfer Keller via air ambulance.
“It was also Dr. Talley’s medical opinion that ‘Ground transportation was simply not an (sic) reasonable option and would have been a horribly bad decision’ for the transfer of Mr. Keller to St. Louis – three hours from Paducah, Kentucky – and ordered the transfer to be conducted via air ambulance,” the suit states.
Keller then received a life-saving emergency coronary artery bypass graft surgery on May 30, 2017, by cardiothoracic surgeons, the suit states.
The cost for Air Evac Lifeteam to transfer Keller to Barnes was $58,444.76.
Keller alleges he is a vested participant in a group insurance policy for employees of IBA-Carrolton Bank, in which the defendant provides health insurance coverage. Air Evac submitted a request for payment to UnitedHealthcare under Keller’s insurance policy.
UnitedHealthcare denied the claim on Aug. 1, 2017, on the grounds that the service provided was not medically necessary.
“As a result of United’s refusal to pay, Mr. Keller is responsible to satisfy the outstanding balance with Air Evac,” the suit states.
Keller claims he filed an internal appeal of UnitedHealthcare’s denial and participated in a review of the denial conducted by the Illinois Attorney General, therefore exhausting all administrative remedies.
“United’s refusal to pay the benefits was arbitrary and capricious, and not based on substantial evidence, was a breach of their fiduciary duties and was the product of a conflict of interest and serious procedural irregularities,” the suit states.
Keller seeks injunctive relief to prevent UnitedHealthcare from denying the claim, equitable relief as provided by ERISA and reimbursement, attorneys’ fees and costs, pre- and post-judgment interest, and all other relief the court deems just.
Keller is represented by Matthew Davis and Adam Olszeski of Gallagher Davis LLP in St. Louis.
U.S. District Court for the Southern District of Illinois case number 3:20-cv-487