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Claim Against an HMO for Denial of Care of a Child is Settled

In May 1999 while insured with HIP, Nicole Coombs, age 9, was diagnosed with medulla blastoma, a terminal cancer in the cerebellum portion of the brain. The doctors at Jackson Memorial Hospital excised the tumor, which left Nicole with residual problems in her fine and gross motor skills.

In July 1999, while still insured by HIP, Nicole began a protocol of radiation, chemo physical and occupational therapies. In the fall of 1999, Nicole's parents attended an open enrollment meeting and, based on representations made by the AvMed representative, switched from HIP to AvMed to cover their daughter Nicole for the 2000 calendar year. At the open enrollment, AvMed promised Nicole would receive the same treatment she had been receiving including unlimited physical and occupational therapies. AvMed also promised to waive any co-pay for inpatient admission and to enroll Nicole in the Medical Case Management Program.

In May 2000, AvMed cut off Nicole's physical and occupational therapies, against her own treating doctors' recommendations. At that time, AvMed also removed her from the Medical Case Management Program where she lost the benefit of a case manager. As a proximate result, Nicole suffered physically and mentally and her parents suffered mentally as well.

The parents, individually and on behalf of Nicole, brought claims for Breach of HMO Contract; Fraud in the Inducement; Promissory Estoppel; Intentional Infliction of Emotional Distress to Nicole Coombs and Intentional Infliction of Emotional Distress to Michael Coombs and Deborah Coombs.