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November 2013 Archives

Court recognizes fiduciary breach claim when health insurer gives erroneous information

Killian v. Concert Health Plan, 2013 U.S.App.LEXIS 22657 (7th Cir. November 6, 2013). Most private insurance plans require pre-certification before hospital admissions; and a major cost-savings method used by insurers is to negotiate rates with "preferred" providers. The utilization of a preferred provider network encourages plan participants to utilize the services of the preferred providers or pay a higher share of the medical costs. But what happens when an insured calls his insurer to verify that a hospital is in-network or to obtain pre-approval for a hospitalization and the insurer's customer service representative gives erroneous or misleading information. That is what happened to Susan Killiand her husband James under the most extreme of circumstances. Susan, who had been diagnosed with lung cancer that had spread to her brain needed emergency surgery. Susan's regular physicians could not perform the surgery and recommended that she receive a second opinion from Rush University Medical Center, one of the major university-affiliated hospitals in the Chicago area. Susan's health insurance was through her employer, Royal Management Corporation, which had contracted with Concert Health Plan Insurance Company for coverage.

DeBofsky, Sherman & Casciari, PC