Monday, May 07, 2007

The Fera case decided May 3, 2007

This case involved a denial of preauthorization by the insurer. Typically when something like surgery is needed the doctor seeks to have the surgery preauthorized so it will be paid. Here that was sought and the insurer denied it. The claimant sought penalties but the insurer said it had promptly run the need for surgery by a physician and he said it was not needed so they could deny it. The claimant however had other physicians who said it was needed so he felt the denial was unreasonable. The case went against the claimant at the lower levels as it seemed the insurer had acted promptly and had a basis for denial so the effort to seek penalties was struck down. However at the Court of Appeals level it was decided that merely acting promptly and having one physician advise them the surgery was not needed may not be reasonable given all the evidence and it should go to a hearing not be struck down by summary judgement. Here is the link to the decision:

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