What Do You Mean It's Not Covered: Another Case of "Reasonable Reliance"
Considering Harris' second argument -- that the State should be prohibited from not covering the baby girl -- the court was equally inconclusive. It couldn't find enough fact to make any conclusions about this point, either. "If Quincoses first gave the erroneous advice to Harris in December 1987, or at any point prior to April 1, 1988, Harris could have relied on that advice to her detriment by failing to convert to family coverage before April 1, 1988," it wrote. "The impediment to our adequately reviewing this issue, however, relates to the lack of a sufficient record pertaining to the elements of Harris' reasonable reliance on the representation and her detrimental change in position caused by that representation and reliance." This was effectively a victory for Harris and her daughter. The appeals court reversed the hearing officer's conclusions and remanded the matter with directions for the hearing officer "to take such additional evidence as is necessary to fully resolve the issues presented."
OUT-PATIENT MEDICAL SERVICES AND SUPPLIES COVERAGE -- We will pay benefits for the out-patient medical services and supplies named below. We will pay: (1) 80% of the expense incurred during a policy year; (2) up to the maximum benefit amount shown on page EI2,5. Out-patient Medical Services and Supplies (a) x-ray and fluoroscopic examinations; (b) radium, or other radioactive substance; (c) electrocardiograms, microscopic, and laboratory tests; (d) drugs and medicines which may be purchased only on the attending physician's written prescription and which are dispensed by a licensed pharmacist; (e) casts, splints, braces, and crutches; (f) artificial limbs; (g) oxygen and equipment used for its administration; (h) emergency room or operating room; and (i) tetanus anti-toxin. The above items are payable when furnished on an out-patient basis at a hospital, clinic, the doctor's office, or an ambulatory surgical center.
