Gamini v. Quartz Health Benefit Plans Corporation (Health Insurance Claim Denial)

In Gamini v. Quartz Health Benefit Plans Corporation (2020AP1442), the District IV Court of Appeals upheld a health insurer’s denial of an insurance claim.

Facts

Gamini’s son was visiting another country when he began experiencing severe dental pain. An X-ray revealed four impacted wisdom teeth, which were removed by an oral surgeon. The family was billed $4,600, which they paid in full. Gamini then filed a claim under his health insurance policy with Quartz, which also insured his son; Quartz rejected the claim because the procedure was preformed at an out-of-network hospital and Quartz determined that the procedure did not qualify as emergency or urgent care. Gamini appealed with Quartz, which again denied the claim. Gamini then filed a small claims action against Quartz for the full cost of the procedure. The circuit court upheld Quartz’s claim denial. Gamini appealed.

Discussion

Following Wisconsin Supreme Court precedent, the appellate court treated the interpretation of the insurance contract as a question of law reviewed de novo. Precedent dictates that the circuit court’s findings of fact should be upheld unless clearly erroneous. Gamini argued that the circuit court erred when determining that his son’s procedure did not meet the policy’s definition of emergency or urgent care. The appellate court rejected this argument and upheld Quartz’s denial of Gamini’s claim.

This opinion was not published.

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