Insurance Coverage/ERISA — Bad Faith Denial of Insurance Benefits for Prosthetic Limb Full Benefit Paid plus Attorneys Fees (Florida 2008)

Insurance Bad Faith

Conal Doyle obtained a settlement in Hughes v. Aetna, a lawsuit filed in federal court in Florida, forcing Aetna Insurance to pay the full amount of the benefit at issue and $25,000 in attorneys fees prior to any discovery being conducted in the case. The plaintiff, Karen Hughes, is an above the knee amputee, who was denied a microprocessor knee (C-Leg) by Aetna, her health insurance company. Aetna alleged that the C-leg, on the market in the United States since 1999, was “experimental and investigational” and thus initially denied the benefit. On appeal, Aetna determined that the C-leg was not “experimental and investigational” and authorized payment.

Nevertheless, Aetna failed to pay for the benefit for more than eight months, forcing Ms. Hughes to file suit in federal court. Due to the fact she was insured by an employer health plan, Ms. Hughes’ claim was governed by ERISA, a federal statute that pre-empts state law and limits recovery to the value of the denied benefit and provides a federal judge discretion to award attorneys fees.

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