What Do You Mean It's Not Covered: The Insurance Company Denies Coverage

Enterprise denied reimbursement for Svec's claim under the group medical insurance policy in a letter to Research Organics dated July 28, 1989. Within a few months of the denial, Svec left Research Organics and sued Enterprise, alleging it had improperly rejected her claim for $5,304 in expenses incurred at Marymount Hospital for treatment of rhinitis and sinusitis during March 1989. She alleged this denial was based upon an undisclosed preexisting condition exclusion in the group master medical insurance policy between Enterprise and her former employer, Research Organics, Inc. Svec's complaint against Enterprise alleged breach of contract, breach of fiduciary duty, and intentional infliction of emotional distress based on Enterprise's failure to pay certain medical expenses pursuant to a group medical insurance contract. Enterprise filed an answer and amended answer and counterclaim denying the substantive allegations of Svec's complaints. Enterprise's answers raised affirmative defenses denying liability under the group medical insurance policy based on exclusions for: preexisting conditions, conditions which arose in the course of employment, and medical conditions for which Svec was entitled to workers' compensation benefits. (Svec had, in fact, filed a workers' compensation claim relating to the same condition in June 1989. It was finally disallowed in December 1990.)