Insurers Remove Dispute Over Conflicting Health Plans to Federal Court

On Friday a case was removed from the 12th Judicial Circuit of Illinois to the Illinois Northern District Court. The case was filed by two parents against the Ludlow Consolidated School District 142 Health Plan administered by Blue Cross Blue Shield, Quality Network Solutions, Aetna Life Insurance Company, the Pediatric Faculty Foundation Inc., Silver Cross hospital, and Vision Financial Recovery Inc. The case is regarding the proper processing and coverage of claims between two different insurance plans regarding a newborn.

When a newborn has health insurance coverage through both parents, an issue can arise as to which plan is primarily responsible for the claims and which plan is secondary and makes payments only after the initial payment has been made by the primary. The plaintiffs, the Bushes, had a daughter in 2019 who suffered from complications in her birth and required further treatment. The infant was insured under both the father’s and the mother’s health insurance provided through their employment. While the treatment was originally covered and paid for with Aetna as the primary insurer, Aetna later recouped this payment, arguing that BCBS was the primary and they would need the explanation of benefits from BCBS to determine their further payment.

BCBS reviewed the claim and originally authorized the treatment. However, after the denial of benefits from Aetna reviewed the policy and claimed that there was no dependent coverage available under the mother’s policy and denied payment. The parents conferenced both parties in order to try to resolve the coverage, as well as pursuing administrative appeals regarding the denials. However, both insurance plans are adamantly not permitting payment.

The plaintiffs are suing for breach of contract, violation of proper ERISA plan processing, violation of the Illinois Consumer Fraud act, declaratory judgment, and violation of the Federal Debt Collection Practices Act against the recovery company for proceeding with attempting to collect judgment while the insurance appeals were still processing.

The plaintiffs are represented by Edelman Combs Latturner & Goodwin. Aetna is represented by the firm of Gordon & Rees