WHEELING – A Wheeling couple says their insurance company wrongly denied their daughter's speech therapy in March, despite covering the service in months past.
James and Ali Robinson, individually and as parents of Riley Robinson, a minor, filed suit July 8 in Ohio Circuit Court against Highmark West Virginia Inc., doing business as Highmark Blue Cross Blue Shield of West Virginia.
According to the complaint, the defendants have denied the plaintiffs' daughter's services not once, but twice in the past two years.
The first denial came in February 2012, when the insurance company said the services did not satisfy the criteria for medical necessity. On March 30, 2012, following an appeal by the Robinsons, the company reversed their denial, finding that Riley's consistent participation in therapy, progress toward goals and participation in a home exercise program showed the medical necessity, and approved payment.
The second denial came in March 2014, again because it did not satisfy criteria for medical necessity. The Robinsons appealed the denial on March 19, with notes about the previous denial based on those grounds and the company's reversal. They also included audio of their daughter's speech and a letter from her speech therapist about the progress that has come with treatment.
On April 23, the insurance company denied the Robinsons' appeal, this time on the grounds that there was no evidence that speech therapy is effective in remediating her condition, the suit states. The plaintiffs challenged the denial, noting that the company changed the baiss for denial and asked for policy provisions that the company was using to deny the claim.
The plaintiffs allege the defendant's appeal process is a sham because they change the reason for denial when presented with evidence that supports a claim. Further, the process allows the company to change the basis given for a denial and does not allow plaintiffs to refute the basis for denial, according to the filing.
The company's actions constitute a breach of implied covenant of good faith and violate West Virginia Code by misrepresenting facts or insurance policy provisions related to coverages.
The Robinsons demand a judgment for compensatory and general damages, as well as punitive damages and court costs. The plaintiffs also ask for pre- and post-judgment interest.
The plaintiffs are represented by attorney Scott S. Blass of Bordas and Bordas PLLC in Wheeling The case has been assigned to Circuit Judge Ronald E. Wilson.
Ohio Circuit Court Case number 14-C-95