Case Overview

This case involves a child born prematurely with a rare neurological condition that causes profound developmental and physical disabilities. His medical providers determined that he requires continuous private duty nursing at home to prevent life-threatening complications and repeated hospitalizations. Despite extensive documentation establishing the medical necessity of his care, the family’s health insurance company repeatedly denied coverage for hospitalizations, procedures, and critical in-home nursing services, forcing Jack’s mother to continually fight for the care he needed. Jack’s mother ultimately filed a lawsuit asserting claims for breach of contract, bad faith breach of contract, and unreasonable delay and denial of benefits under Colorado law. The case concluded with a favorable confidential settlement for Jack and his family.

Case Background

The journey of our client and her young son, Jack, began under challenging circumstances. Born prematurely at 36 weeks on April 4, 2019, Jack’s life immediately presented a daunting medical journey. Genetic testing and an MRI quickly revealed a severe neurological condition: Lissencephaly, a rare brain malformation characterized by a “smooth brain” due to improperly migrated neurons. Diagnosed as a severe Grade 2 with a poor prognosis, it was clear Jack would face profound challenges, and tragically, was not expected to live past the age of ten.

Jack’s Lissencephaly left him severely disabled. He is nonverbal, unable to use his hands, and confined to a wheelchair. His complex medical needs are extensive: low muscle tone, chronic respiratory failure, an inability to swallow requiring 100% feeding tube dependency for nutrition and medication, severe drug-resistant epilepsy, cortical blindness, and a Type 1 laryngeal cleft with a constant risk of aspiration. He cannot clear his airways without assistance and has poor pulmonary reserve, necessitating noninvasive ventilation and frequent oral, nasal, and deep suctioning multiple times a day.

This fragile life demands constant, intense medical attention – “around-the-clock, near hospital-level care at home,” which, critically, can only be provided with professional private duty nursing. Without this continuous support, Jack faces life-threatening events, a diminished quality of life, and recurrent ICU admissions for acute respiratory failure. Indeed, since his birth, Jack has been hospitalized multiple times in the intensive care unit for such crises.

Constant Coverage Denials for Jack’s Medical Care

Jack’s mother held a health insurance plan with a major health insurance company that was governed by Colorado law. Under this plan, the health insurance company was obligated to cover “Medically Necessary” services and supplies. From the outset, Jack’s medical providers, along with his mother, submitted extensive documentation demonstrating the undeniable medical necessity of his hospitalizations, procedures, and, crucially, the in-home private duty nursing services required to keep him alive and comfortable.

However, despite knowing the full extent of Jack’s condition and the medical evidence supporting his care, the health insurance company issued repeated denials. Jack and his family faced repeated, willful, and wrongful delays and outright denials of coverage for Jack’s essential hospitalizations, procedures, and the vital private duty nursing care. These decisions were made, according to the complaint, “under the guise that the medical treatment was not medically necessary,” even though the treatment consistently met the definition of medical necessity under the Plan and Colorado law.

The consequence for Jack was devastating: repeated hospitalizations, suffering, and a negatively impacted quality of life. For Jack’s mother, already shouldering the immense burden of caring for a terminally ill child, it meant “countless hours” spent on the phone and exchanging emails with the health insurance representatives, desperately fighting for the coverage Jack was owed.

The Fight for Damages for the Past Coverage Denials and Securing Coverage for Jack’s life

Driven by the alleged injustice and the ongoing threat to her son’s well-being, Jack’s mother, individually and as Jack’s guardian, filed a Complaint and Jury Demand against the health insurance company. The lawsuit asserted three claims against the health insurance company: breach of contract; bad faith breach of contract; and unreasonable delay/denial pursuant to C.R.S. §§ 10-3-1115 and 1116. We also alleged pain and suffering on behalf of Jack, and his mother and father.

This case resulted in a favorable confidential settlement for Jack and his family. Additionally, Jack will receive in-home private duty nursing for his lifetime. This has significantly increased Jack and his family’s quality of life. The family was also able to move into a new home and modified the home so it was more accessible for Jack.