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ARTICLE ID 28706

$79.6 MILLION INCLUDING $78.5 MILLION IN PUNITIVE DAMAGES AGAINST HMO - CHILD WITH CEREBRAL PALSY TERMINATED FROM CASE MANAGEMENT PROGRAM - FOUR MONTH LOSS OF SPEECH, OCCUPATIONAL AND PHYSICAL THERAPIES - REGRESSION IN COMMUNICATIONS AND FINE MOTOR SKILLS - EMOTIONAL DISTRESS.

Palm Beach County, Florida

The plaintiff alleged that the defendant health plan, Humana Health Insurance Company of Florida, wrongfully terminated a special case management program to a five-year-old girl who suffered from cerebral palsy. The plaintiff claimed that the termination was designed solely as a cost-cutting measure by the defendant and resulted in emotional distress and a regression of the young girl’s condition. The defendant was in default at the time of trial due to failure to meet discovery deadlines and the case was tried on damages only. The defendant maintained that the minor plaintiff was out of the case management program for only four months, that her benefits were not terminated and that her condition was not altered as a result.

The plaintiff father, a Palm Beach County sheriff’s officer, was a subscriber to his employers group health insurance policy. On December 14, ________, his wife gave birth to a daughter with cerebral palsy. The plaintiff’s evidence showed that cerebral palsy children require systematic and regular occupational, physical and speech therapy, all of which were provided under the family’s group health insurance plan. In ________, the plaintiff’s employer switched to the defendant Humana Health Insurance Company of Florida as the provider of group health insurance for its ________ employees. The new coverage was represented to be a no- loss/no-gain policy which carried the additional benefit of medical case management ("MCM"). MCM was represented as an innovative program for catastrophically and chronically ill patients to improve management of their care. MCM also waived deductibles and co-pays.

For 23 months, the minor plaintiff received all of her benefits in the MCM program. However, on December 1, ________, the family received a letter from the defendant which stated that it had been determined that the minor plaintiff no longer met the requirements of the MCM program and would be returned to their regular plan benefits effective December 12, ________. Upon receipt of the letter, the plaintiff father testified that he went to see the on-site Humana representative. The plaintiff testified that the representative called Humana’s corporate offices and then confirmed that not only was the plaintiff’s daughter, Caitlyn, terminated from the MCM program, but Humana would no longer be providing her with benefits for speech, occupational or physical therapies.

The plaintiff contended that pursuant to the MCM policy and procedure manual, the "closure phase" (removing a member from the MCM program) can occur only when there is a "thorough and systematic examination of the case to ascertain when maximum potential is reached." The plaintiff alleged that Caitlyn’s condition had never stabilized and that the program services were extremely important and necessary for her. p 7 3 The plaintiff introduced evidence that in August of ________, Humana’s management in conjunction with its Utilization Department made the unilateral decision to terminate not only Caitlyn, but over ________ other catastrophically ill or injured children from its MCM program. According to Humana, these other catastrophically ill or injured children were similar to Caitlyn in that they were allegedly "static" and had reached their maximum improvement. However, the plaintiff claimed that just the opposite was true and that the children who most desperately needed the medical services were terminated.

The plaintiff alleged that the business decision to terminate over ________ catastrophically ill or injured children was a deliberate scheme of aggressive cost-cutting activities initiated and implemented by the defendant in order to produce the greatest possible financial return to Humana. Use of "Disease Management" companies were implemented to lower hospitalizations and bonuses and incentives were given to produce decisions which generated the most savings, according to the plaintiff. The plaintiff also contended that Humana saved money by systematically delaying payment or in many cases refusing to pay providers for treatment and care of Humana’s members. Evidence indicated that the turnaround time for Humana to pay bills for treatments to catastrophically ill or injured members was in many cases 90, ________, ________ days or longer.

The plaintiff claimed that as a result of Humana’s actions of terminating Caitlyn from its MCM program and then denying benefits, Caitlyn lost speech therapy as well as occupational and physical therapies. The plaintiff claimed that the little girl physically regressed in both her communications and fine motor skills with led to severe emotional distress.

The defendant argued that the minor plaintiff was only out of the MCM program for approximately four months before being reinstated to the program. The defendant argued that a board-certified physician authorized Caitlyn’s removal from the MCM program and Caitlyn’s treating neurologist testified that the girl did not regress and suffered no emotional distress as a result of the short absence from the program. The defense argued that Caitlyn’s benefits were never dropped and that she actually underwent more therapy sessions after she was out of the MCM program. The defense contended that the only change in Caitlyn’s coverage was that a nurse administrator no longer oversaw her care and her family became responsible for regular deductibles and co- payments. The defendant maintained that Caitlyn had progressed to the level where administrative coordination of her care was no longer necessary.

The jury found for the plaintiff in the amount of $79.6 million.

The award included $78.5 in punitive damages; $1 million for Intentional Infliction of Emotional Distress; $________ for Fraud in the Inducement of the Contract; $________ for Insurance Bad Faith; $________ for Promissory Estoppel and $________ for Breach of Contract. An appeal is expected.

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