|
No.131711
| Desiree E. Ross, Personal Representative of the |
|
Andrew B. Wachler |
| Estate of Douglas G. Ross, |
|
|
Petitioner-Appellee, |
|
|
| v |
(Appeal from Ct of Appeals) |
|
|
(Wayne - Callahan, M.) |
|
|
| Blue Care Network of Michigan, |
|
Phillip J. DeRosier |
| Respondent-Appellant. |
|
|
| __________________________________________ |
|
|
Click to view briefs in Adobe format:
Petitioner-Appellee's Brief in Opposition to Application for Leave to Appeal>>
Petitioner-Appellee's Supplemental Brief>>
Respondent-Appellant's Application for Leave to Appeal>>
Respondent-Appellant's Reply Brief>>
Respondent-Appellant's Supplemental Brief>>
Commissioner of the Office of Financial and Insurance Services' Amicus Curiae Brief>>
Background
Douglas Ross, a Blue Care Network insured, suffered from an extremely virulent form of multiple myeloma. When he had exhausted his known available in-network treatment options, he sought treatment at a facility in Arkansas that specialized in treating multiple myeloma, but he did not obtain Blue Care Network’s pre-authorization for that treatment. Blue Care Network refused to cover this out-of-network medical care. The petitioner, the personal representative of Ross’ estate, appealed Blue Care Network’s decision to the Commissioner of the Office of Financial and Information Services. The Commissioner assigned the case to Permidion, an independent review organization, pursuant to the Patient’s Right to Independent Review Act (PRIRA). The independent review organization recommended that Blue Care Network’s denial of coverage be overturned. Despite this, the Commissioner upheld Blue Care Network’s denial, with the exception of a two-week hospitalization which she ruled constituted “emergency care.” The circuit court reversed this ruling on appeal, ordering Blue Care Network to pay for all of Ross’ medical care at the Arkansas facility. The Court of Appeals affirmed the circuit court’s ruling in a published opinion, with the exception of certain services the Commissioner had not considered or ruled on. The Court of Appeals reasoned that the Commissioner had erred by discounting the independent review organization’s medical recommendations and replacing them with her own, independent conclusions, which was beyond her authority under PRIRA. Blue Care Network appeals.
Top of Page
|
