Participant to Get Benefits for Claim not Related to Obesity Surgery

November 16, 2005 (PLANSPONSOR.com) - The US District Court for the Northern District of Oklahoma has ruled that a participant can receive benefits for his claims related to chronic gall bladder disease because it was not related to his stomach banding surgery.

In his opinion, US District Judge James Payne ruled that Fortis Insurance Co. acted arbitrarily in denying benefits to the participant.   Payne said Fortis failed to review the participant’s objective medical evidence, including medical test results, doctor’s notes, medical charts, and letters, and the insurer lacked sufficient evidence for denial of the claim.

In 2000, Bruce Lucenta underwent stomach banding surgery to treat his severe obesity.   The medical plan excluded coverage for services related to weight reduction.   The court said Lucenta suffered sever medical problems over 18 months following his surgery.   Lucenta’s doctor finally determined that he had gall bladder disease and he had surgery to remove his gall bladder.   According to the court, Fortis partially paid for Lucenta’s gall bladder removal but denied any post-surgery medical care.

The court rejected Fortis’ argument that the record did not indicate that any disease or condition existed prior to the stomach banding surgery, pointing out that the insurer had paid for a medication for Lucenta’s upper gastrointestinal pain for ten months before the stomach banding surgery.   Noting that after the gall bladder surgery Lucenta did not require further medical attention the court found that Fortis’ contention that the ongoing medical problems were related to the stomach banding surgery was incorrect.

The case is Lucenta v. Fortis Insurance Co., N.D. Okla., No. 02-CV-955-JHP-SAJ, 11/8/05.

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