Kaiser Refuses to Honor Insurance, a Utah Hospital Claims
2-25-2015 22:40:00

(CN) - Kaiser is using a pretext to avoid paying for medical bills, a hospital alleges in a Utah Superior Court complaint.

Primary Children’s Hospital says Kaiser owes it money after caring for one of its insurance beneficiaries in January 2012. 
A 14-year-old minor was admitted to Primary in Salt Lake City on Jan. 15, 2012. The teen, suspected of suffering from a rare digestive disorder, checked out of the hospital a week later, on Jan. 22.
The visit cost over $25,000, of which about $14,000 was paid by primary insurer BlueCross and Blue Shield.
The remainder, about $11,000, was supposed to be paid by Kaiser Foundation Health Plan, an employee welfare benefits plan under the Employee Retirement Income Security Act.
Kaiser refused to pay, however, alleging it never received the appropriate medical records, a claim Primary refutes.
“The plaintiff sent an appeal letter on Aug. 31, 2012, indicating that medical records had already been sent to them on several previous occasions, but nonetheless, they were enclosed once again with this appeal letter,” according to the complaint. “The defendant then denied the claim for lack of an itemized billing statement.”
Primary says it can’t give Kaiser the billing statement because it’s confidential and contains proprietary information. 
Kaiser failed to respond to a final appeal letter sent in September 2014 and to Primary’s request for copies of the Plan Document and Summary Plan Description.
Primary is suing for recovery of plan benefits, breach of fiduciary duties and failure to produce plan documents under federal law. The plaintiff seeks a total of $11,380.35 in unpaid benefits, a court order penalizing Kaiser $110 per day following 30 days after the dates of the requests for plan documents and attorneys’ fees.
Primary is represented by Marcie Shaap, in Salt Lake City, Utah.