Pro Se Plaintiff Prevails Against Health Insurance Company

Posted on July 30, 2007 by Jeffrey V. Mehalic

    A recent decision from federal court for the Southern District of West Virginia illustrates what happens when a health insurance company uses questionable judgment in trying to save a few (in this case, very few) dollars. 

    In Juniper v. M&G Polymers USA, LLC, 2007 WL 2028844 (S.D.W.Va. 2007), Judge Robert C. Chambers granted summary judgment for the plaintiff, Samuel Juniper, who was pro se for almost the entire case, and against the defendant, M&G Polymers USA, LLC, the plaintiff’s employer and plan administrator.  Brian King of the ERISA Law Blog wrote about the case a few days ago.

    Aetna, M&G's health plan insurer, denied $40 in charges for three venipunctures.  Juniper pursued the matter and was given various and apparently conflicting reasons for the denials by Aetna and by M&G.  He filed suit against M&G in Mason County (West Virginia) Magistrate Court (which has a $5,000 jurisdictional limit) in order to obtain payment for the charges.

    M&G removed the case on the grounds it was preempted by ERISA.  It does not appear that there was any discovery in the case, other than production of the administrative record, which would be typical in an ERISA case. The parties filed cross-motions for summary judgment.   Magistrate Judge Maurice G. Taylor, Jr. recommended that Juniper’s summary judgment motion be granted and that M&G’s be denied.  M&G objected to Judge Taylor’s recommended decision, at which point counsel for Juniper made an appearance.  Judge Chambers affirmed the recommended decision on the grounds that the "decision [to deny the charges] was arbitrary, not supported by evidence,  inconsistent with earlier interpretations of the plan and  not reasonable."

    As Brian King points out, the case was not worth a lawyer’s involvement for $40 in denied charges, but could turn into a class action based on Aetna's misconduct.  He also notes that while the case is an example of what health insurers do to patients and providers every day, it also represents an example of an insurer that did not get away with cutting corners. 

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Comments (1) Read through and enter the discussion with the form at the end
jim gray - May 28, 2010 3:24 AM

My ERISA pension plan also has problems understanding the plan document.

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