Gonzalez v. Blue Cross/Blue Shield of Alabama

Marco and Theresa Gonzalez (plaintiffs) applied for health-insurance coverage from Alfa Mutual Insurance Company (Alfa) (defendant). Blue Cross/Blue Shield of Alabama (Blue Cross) (defendant) was Alfa’s claims administrator. The policy required a 365-day waiting period for maternity-care benefits unless the expected delivery date was after the waiting period’s expiration and delivery occurred before that date. The Gonzalezes’ maternity-benefits waiting period was to expire on February 28. Theresa became pregnant. An ultrasound identified the expected delivery date as February 26, and a doctor’s report identified it as February 27. Theresa gave birth four days before the waiting period expired. The hospital-admission summary listed the expected delivery date as February 27. Blue Cross rejected Theresa’s hospital-stay claim and later determined other claims were paid in error. Marco requested an explanation. The hospital and Blue Cross explained that the waiting period had not expired. Marco submitted information from Theresa’s doctors indicating an expected delivery date after February 28. Blue Cross responded that the information conflicted with other records and it would reconsider the claim. Gonzalez sued Blue Cross alleging bad-faith refusal to pay the hospital-admission claim. The trial court granted summary judgment to Blue Cross. The Gonzalezes appealed.