GRAMMAR! HOW VERB TENSE WON A HEALTH INSURANCE LAWSUIT!
June 13, 2018
Many “trial lawyers” crow about how much money they make for themselves and their clients. We’re not of that ilk.
Every case is important to the client, and for us.
Let me tell you about a recent case of ours that I’m just tickled about.
We represent a wonderful woman who has been a public school teacher for 24 years. Since then, she’s had and paid for, group health insurance through the school board.
in 1998, she had a gastric by-pass procedure, covered by her group health insurance. The surgery was successful.
11 years later, in 2009, she began to have very severe gastric problems. She sought the advice of her doctors.
She had two unsuccessful procedures, to clear blockages. Both procedures, were fully covered by her group health insurance.
Finally, in 2014, a specialist at the Mayo Clinic, diagnosed the problem. The surgical mesh that was used in the 1998 Gastric by-pass procedure was deteriorated. The mesh needed to be removed, and the area treated.
The procedure cost about $70,000.
Now……… the 2014 version of the group health insurance policy excluded any coverage for weight control procedures, and a second part of the policy excluded coverage for any complications of anything that was not covered. While the 2014 revision surgery was not for weight control, it was certainly needed to fix a complication of the 1998 surgery……….
The group health insurer refused to pay for the surgery. Our client appealed the decision to the insurer, unsuccessfully.
Since she had no alternative, she had the surgery, and was saddled with over $70,000 of medical bills, an enormous amount for a Florida public school teacher.
Our client hired local lawyers, who had apparently had little or no experience in health insurance claims, the suit was dismissed twice, and they withdrew.
Even though she lives on the Florida Panhandle, and we are located in West Palm Beach, she found us on the internet, and called me. We re-cast, and re-filed the lawsuit, successfully this time.
The group health insurance policy, like every insurance policy, is drafted in the present, and future tense. Legal Scholars have written some excellent papers about verb tense.
There are a few legal opinions from elsewhere in the Nation, but not Florida, that address verb tense in insurance policies. This case was the first and only such case considered by a Florida state court.
We and the group health insurer filed competing motions for summary judgment, and we prevailed!
Our wonderful client, will have her medical bills paid, with interest, and since there is a Florida Statute that provides for the group health insurer to pay the attorney’s fees, we won’t charge her a cent for our services.