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Lubeznik v. HealthChicago, Inc.

Appellate Court of Illinois
644 N.E.2d 777 (1994)


Facts

Dr. Stiff recommended that Bonnie Lubeznik (plaintiff) undergo a specific form of bone marrow transplant and chemotherapy treatment to treat Stage III ovarian cancer. Lubeznik’s insurer, HealthChicago, Inc. (defendant) required her to obtain approval in advance for elective procedures such as this one. Stiff contacted HealthChicago and requested that it agree in advance to pay for the treatment, known as pre-certification. HealthChicago’s medical director, Dr. Mathy, denied the request concluding that the treatment was experimental and not covered under Lubeznik’s policy. Lubeznik filed suit against HealthChicago requesting injunctive relief to require the insurer to pre-certify her for the treatment. At the hearing, Stiff testified that he had performed the requested treatment on 21 patients with a 75 percent success rate of complete cancer remission. Stiff also testified that the treatment was not experimental and provided supporting documentation. Mathy testified that he denied the pre-certification request because it was experimental. However, it was only after that decision that he obtained supporting documentation from several federal health care agencies that the procedure was indeed experimental. The circuit court granted Lubeznik’s injunction and HealthChicago appealed to the appellate court of Illinois, arguing that the court improperly determined that the treatment Lubeznik requested was covered under her insurance policy.

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Holding and Reasoning (Johnson, J.)

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