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
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 girls 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 sheriffs 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 plaintiffs evidence showed that cerebral
palsy children require systematic and regular occupational,
physical and speech therapy, all of which were provided under the
familys group health insurance plan. In ________, the plaintiffs
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 Humanas corporate offices and then
confirmed that not only was the plaintiffs 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 Caitlyns
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 ________,
Humanas 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 Humanas 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 Humanas 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 Caitlyns removal from the MCM program and
Caitlyns 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 Caitlyns
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 Caitlyns 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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