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David v. Heckler
United States District Court for the Eastern District of New York
591 F. Supp. 1033 (1984)
Joseph David’s (plaintiff) wife received cancer treatment covered by Medicare Part B. Group Health Incorporated (GHI), the private insurance company administering Medicare Part B for David’s wife, approved only partial reimbursement for the cancer treatment services. David challenged the underpayment through GHI’s internal claim review system. After review, David received a review determination letter affirming the underpayment; however, the letter did not contain any specific justifications for the underpayment. At the time, GHI underpaid approximately 83 percent of all eligible Medicare reimbursement claims it processed. David sued GHI and Margaret Heckler, the Secretary of Health and Human Services (the government) (defendant), arguing that the Medicare claim processing procedures violated the due-process rights of Medicare beneficiaries. At trial, David’s expert submitted unchallenged testimony that, although most Medicare beneficiaries read at or below the eighth-grade level, most coverage letters were written for expert readers and featured Medicare jargon that was incomprehensible to laypersons.
Rule of Law
Holding and Reasoning (Weinstein, C.J.)
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