Patient Sues Over Insurer’s Failure to Cover Period Waiting for Treatment

On Monday a case was removed from the Circuit Court of La Crosse County, Wisconsin to the Western District of Wisconsin. The case was originally filed by Brian Elder against Quartz Health Solutions, and alleged that the health insurer failed to pay for medically necessary hospital treatment.

The plaintiff, according to the original complaint, was hospitalized at Gundersen Lutheran Medical Center in La Crosse, Wis. due to an infected wound. After receiving treatment for this would, the plaintiff needed to be transferred to a Skilled Nursing Facility (SNF) to continue further care of the wound. However, as the plaintiff was preparing for transfer on September 25, he received an evaluation from a neuropsychologist, who indicated that the patient had diminished mental capacity and was not capable of participating in his discharge planning and required further evaluation.

Further evaluation occurred the next day, the complaint said, and the same physician noted that while the patient had a mild neurocognitive disorder, that the patient’s condition had improved and discharge planning could now move forward.

However, during this time of evaluation, a placement with an SNF that had the proper wound vac treatment available for the patient was no longer available. The new SNF did not immediately have the treatment available and the patient remained inpatient until October, 3 when the treatment became available. The claims for this stay were submitted to the patients insurance, but coverage for the interval from September 25 through October 3 was denied as not medically necessary.

The plaintiff is suing for declaratory judgment as to coverage, breach of contract, and breach of the implied duty of good faith and fair dealing. The plaintiff is represented by Bosshard Parke, Ltd. The defendants are represented by in-house counsel.