Lawsuit: Claims payment denied for emergency care rendered to plaintiff's late husband

By Nicholas Malfitano | Jan 22, 2019


PITTSBURGH – A health insurance provider is being charged with negligence and bad faith for allegedly denying payment for a claim in connection with emergency medical care administered to a Pennsylvania widow’s late spouse.

The Western Pennsylvania Hospital of Pittsburgh and Linda Brooks Burford (as administratrix of the Estate of Joseph T. Burford) of Pennsylvania filed suit in the Allegheny County Court of Common Pleas on June 14 versus UnitedHealthCare of Pennsylvania, Inc., also of Pittsburgh.

Per the litigation, decedent Joseph T. Burford, 63, purchased a health insurance policy from UHC with an effective date of Feb. 1, 2016. More than seven months later, on Sept. 19, 2016, Burford was found unresponsive in his home. 

An ambulance was summoned and he was transported to Armstrong County Memorial Hospital, the suit says. His condition deteriorated and he was placed on a ventilator, before being transferred to West Penn for continued emergency care, the suit says.

There, he was diagnosed as suffering from bacterial meningitis and declared brain dead on Sept. 20, 2016. After his family decided to withdraw care, he was declared dead the following day.

West Penn submitted a claim for payment to UHC on Sept. 26, 2016, but was denied their claim by UHC for reasons of “medical necessity” on Oct. 10, 2016. The suit claims neither the decedent’s estate or his surviving members were notified of this development.

In November of that year, UHC personnel advised West Penn they were able to appeal the denial by submitting medical records and an appeal form, which was done shortly thereafter, the suit says. Over subsequent months, it was finally revealed to West Penn by UHC that the claim was denied for its being an “out-of-network” facility, the suit says.

In June 2017, the decedent’s estate learned of UHC’s denial of coverage and lack of payment on the claims from West Penn, the suit says. After a series of further appeals spanning from mid-2017 to the summer of 2018, all of which were denied, the plaintiffs referred to the policy as arguing the decedent’s medical was of an “emergency” nature, and thus within the policy’s coverage purview, the suit says.

“At the time of his admission to West Penn, Mr. Burford suffered from a serious medical condition that arose suddenly and which, in the judgment of a reasonable person, required immediate care and treatment. The medical records supplied to UHC demonstrated that the patient’s condition was such that his emergency medical condition was not abated during his brief treatment at ACMH and required immediate transfer to a facility that could provide the level of emergency care necessary to treat his condition,” the lawsuit reads.

For counts of breach of contract and bad faith, the plaintiffs are seeking damages in $44,439.10, plus interest, punitive damages, costs and attorney’s fees.

The plaintiffs are represented by Sean P. Audley of Audley Law Offices, in Pittsburgh.

The defendant has not yet secured legal counsel, according to court records.

Allegheny County Court of Common Pleas case GD-18-017168

From the Pennsylvania Record: Reach Courts Reporter Nicholas Malfitano at nick.malfitano@therecordinc.com

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