Lubeznik v. HealthChicago, Inc. case brief summary
644 N.E.2d 777 (1994)
CASE FACTS
The patient enrolled in a bone marrow program, which contacted the insurance company to arrange pre-certification of insurance benefits as required by her policy. The pre-certification was denied because the treatment was viewed as experimental. The patient sought a mandatory injunction requiring the isurance company to pre-certify her.
DISCUSSION
CONCLUSION
The court denied the insurance company's motion challenging a trial court order, which granted a permanent injunction requiring the insurance company to pre-certify bone marrow treatment for the patient.
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644 N.E.2d 777 (1994)
CASE SYNOPSIS
Defendant insurance
company challenged the order of the Circuit Court of Cook County
(Illinois) granting a permanent injunction requiring the
pre-certification of plaintiff cancer patient's treatment.CASE FACTS
The patient enrolled in a bone marrow program, which contacted the insurance company to arrange pre-certification of insurance benefits as required by her policy. The pre-certification was denied because the treatment was viewed as experimental. The patient sought a mandatory injunction requiring the isurance company to pre-certify her.
DISCUSSION
- The court affirmed the trial court's order granting the injunction.
- The trial court did not err in determining that the treatment was covered under the policy.
- The exclusionary language in the contract was not clear and unambiguous.
- This exclusionary language varied from the Illinois Health Maintenance Organization Act, Ill. Rev. Stat. ch. 111 1/2, para. 1408.5 (1991), that detailed which agencies determined if a treatment was experimental.
- The bone marrow transplant treatment was neither an experimental therapy nor a transplant.
- The insurance company's testimony about a third party's statement that the treatment was experimental was properly excluded as hearsay.
- The patient was eligible for the treatment, had a high chance of recovery with the treatment, and would suffer irreparable harm without the treatment.
CONCLUSION
The court denied the insurance company's motion challenging a trial court order, which granted a permanent injunction requiring the insurance company to pre-certify bone marrow treatment for the patient.
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