Spinal Surgery Patient Wins Suit Over Insurance Coverage Denial

A Central States health insurance plan improperly refused to pay for a woman’s spinal surgery, because a reviewing doctor’s recommendation to deny coverage wasn’t based on her full medical record, a federal court said.

Central States, Southeast and Southwest Areas Health and Welfare Fund Active Plan, an Employee Retirement Income Security Act fiduciary, didn’t provide the doctor with complete copies of Dorothy Garner’s medical records, including an MRI and her surgeon’s office notes, according to the U.S. District Court for the Middle District of North Carolina.

The doctor’s denial recommendation thus was based on his belief that the records didn’t ...