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Representative Cases Involving Health Insurance Coverage

Following are examples of actual verdicts and settlements obtained by Pillsbury & Coleman in cases involving claim denials or underpayment for individual health care policies. Additional results can be reviewed when you speak with an attorney at our firm. If plaintiff or insurance company names do not appear it is because confidentiality agreements are in place restricting that information.

Zembsch Family v. Health Net of California, Inc.

Case Issue

Insurance bad faith, claim denial for life-saving surgery

Summary

Jack suffers from Metatropic Dysplasia (MD), an extremely rare form of dwarfism. Jack's MD condition is characterized by shortened limbs and a badly deformed spine, which worsens as he grows. His vertebrae are extremely soft, resulting in many complications, which can lead to permanent pain, paralysis or death and substantially complicates corrective procedures. He suffers from severe kyphoscoliosis, which is a condition involving severe hunchback curving of the upper spine and scoliosis, a twisting throughout the spine. Jack suffered from, and as his disease progresses, he will continue to suffer from osteoarthritis, ligament, cartilage, and connective tissue damage. Those conditions combined with his bone deformity will lead to restrictive lung disease if he does not receive proper treatment.

As a result, his internal organs are threatened. His lungs and heart may not have room to function properly and are in danger of serious damage of being literally crushed by the severe abnormal curvature of the spine. The twisting and bending of his spinal column may result in damages to the spinal cord, paralysis or death. His potential height is quite short and his life expectancy, without proper care, is severely shortened.

Jack is in urgent need of care from a specialist in MD and can be expected to undergo numerous surgeries during his life. Of immediate concern is the necessity for appropriate surgery to prevent damage to his spinal cord and internal organs, such as his heart and lungs. Such surgeries are extremely complex and the risk of injury, paralysis or death is very significant. Further, both the manner and rate of Jack's growth is unpredictable, thereby requiring constant medical management by a physician skilled in the treatment of MD. Jack was in immediate need of care from a specialist with actual experience in the treatment of and surgical needs of MD children.

Tough Negotiators, Passionate Litigators

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