Well Care Reneges On Promise To Pay For Insured Patients Needed Surgery
- Insured Forced To Sue Company For Bad Faith -
Attorney, Ted Leopold, partner in the firm of Ricci~Leopold, PA have filed a lawsuit on behalf of Gladys and Alvin Solomon against Well Care HMO, Inc.
In March of 1998, Gladys Solomon obtained health services coverage with Well Care under an HMO plan identified as the “Ultimate 10” Individual Health Benefit Contract. During this period Mrs. Solomon began receiving treatment from a Well Care contracted provider, Dr. David Lashway. Dr. Lashway discovered uterine fibroids in Mrs. Solomon and ultimately recommended that she undergo a total abdominal hysterectomy.
Following Dr. Lashway's diagnosis and recommendation for surgery, Well Care provided authorization for the surgery for medical necessity. At that time Well Care did not guarantee payment of the claim for Mrs. Solomon pending their investigation of a potential “pre-existing condition.” Well Care subsequently performed its investigation and determined that the pre-existing condition exclusion did not apply to her necessary surgery and authorized payment for the procedure. Mrs. Solomon underwent various pre-operative testing in preparation for the abdominal hysterectomy. On the afternoon of June 19, 1998, Dr. Lashway's office contacted Mrs. Solomon and informed her that Well Care would not guarantee payment for the procedure scheduled for June 22, 1998. She and her adult daughter immediately contacted Well Care to determine the reason for the change in the company's earlier authorization and guarantee of payment. They were informed that authorization had been revoked, with not other explanation.
Without Well Care's agreement to pay the doctor, hospital and other costs associated with this major surgery, and because she as are many Americans, unable to afford the tens of thousands of dollars in costs and expenses associated with the treatment without her HMO plan, Mrs. Solomon was basically forced by Well Care to cancel the surgery at that time.
Six months elapsed without the needed surgery being performed and Mrs. Solomon's health failed. She remained in constant pain and was practically bedridden. Mrs. Solomon finally had to be admitted to the hospital on an emergency basis and had the medically necessary operation due to her critical health condition.
Following the surgery the bills began pouring in. Mrs. Solomon hired an attorney and through her counsel filed the necessary formal grievances with Well Care, however, to a deaf ear of the company and no avail.
Well Care materially breached its promises and obligations under the plan by failing to authorize payment of benefits for a medically necessary surgery. Mrs. Solomon made all of her premium payments to the company, moreover, was told prior to the surgery that it was authorized. However, Well Care decided something different just days before a necessary procedure was to be performed. This woman's health was put at complete risk by Well Care.
In the suit that was filed by Ricci~Leopold, PA on behalf of the Solmon's it is stated that prior to enrolling in the plan, Well Care, through its representatives and agents, concealed critical information from Mrs. Solomon and thereby made false and fraudulent misrepresentations which induced her to enroll in the plan. But for this pre-plan misconduct by Well Care, Mrs. Solomon obviously would never have enrolled in this HMO. The suit provides a more in-depth explanation of the misconduct of Well Care, however, much of what it boils down to is that this company breached its contract with Mrs. Solomon and committed fraud.
In the suit the Solomon's are seeking unspecified damages. The suit was filed in the Circuit Court of the 15th Judicial District in and for Palm Beach County, Florida on April 12, 2001.
This is the first time that the public has seen some disturbing news about Well Care and its practices. We hope that the Solomon's case will assist other folks in receiving the services and healthcare that they pay and contract for from this company, and will send a message that insurance providers have got to keep their contractual commitments and perform with good faith. People's lives are at stake here and this particular company did not seem to care about that, we hope this suit will change the way they do business.
Some interesting topics to read about - Bextra
