A Madison law firm has filed a small-claims lawsuit against Dean Health Plan over its partial denial of a customer's medical bills, as detailed in an Isthmus article last year ("Unable to Resolve Your Complaint," 10/22/09).
"Dean's denial...was arbitrary and capricious, unsupported by substantial evidence, erroneous as a matter of law, not made in good faith and in violation of [federal law]," states the complaint, filed June 1 by Andrew Erlandson of Hurley, Burish & Stanton, headed by Madison lawyer Steve Hurley. It also charges "breach of contract" and calls for full restitution, plus interest, punitive damages and attorney's fees.
The case concerns a Madison man, identified in the article by the pseudonym Joe Kay, who ended up in an emergency room after cutting his hand. But Dean Health Plan paid only $454 of the $1,100 bill, saying the rest was for unspecified "ancillary services," which as near as Kay could figure were for the stitches to sew up his wound.
"Contrary to Dean's interpretation of its policy," the complaint states, "sealing a severe laceration with stitches during the course of emergency room treatment does not fall under the policy's definition of 'ancillary services.'"
Dean has consistently refused to explain, even to state regulators, what it meant by ancillary services. HMO spokesman Pete Thompson says medical privacy rules prevent it from commenting on the lawsuit.
But Erlandson was contacted last week by Dean - curiously, on the same day that Isthmus asked Dean about the lawsuit. "Dean expressed an interest in settlement," he says, "and those discussions are ongoing."