Civil Litigation

Insurance Coverage Denial Leads to Class Action Suit

C. David Durkee

When Logan Wealcatch of Plantation was 3 months old, doctors diagnosed him with a severe deformation of the skull called plagiocephaly. Specialists immediately outfitted the infant with a corrective helmet to realign his skull and prevent permanent facial deformities, along with hearing and vision problems.

But when Logan’s parents, Matthew and Alison Wealcatch, submitted the $2,000 bill to Blue Cross Blue Shield of Florida (BCBSF), they received a letter informing them that the helmet was a cosmetic accessory and would not be covered. Now, the Wealcatches are suing the insurance company on behalf of their son, as well as the families of other children suffering from plagiocephaly, a condition that affects one in 10 newborns in the United States, according to the Journal of Craniofacial Surgery.

They filed a federal class action suit on Feb. 5, demanding that BCBS reimburse their medical expenses and set a categorical precedent for covering future plagiocephaly treatments. The court has not yet decided whether the suit will have class action status.

“We are filing this lawsuit to change things for other families,” Alison Wealcatch said. “Insurance companies cannot arbitrarily tell their customers what is and is not medically necessary.”

The Wealcatches’ situation is not unusual, said Dr. Eric Stelnicki, director of the Joe DiMaggio Children’s Hospital Cleft and Craniofacial Center in Hollywood.

Stelnicki, who diagnosed Logan with severe plagiocephaly, said the condition is “not a cosmetic problem, but a true acquired deformity caused by a medical recommendation that children sleep on their backs.” He added that, within insurance companies, coverage decisions often are made by nurses or administrators with little knowledge of a patient’s unique condition.

BCBSF officials said they could not comment on pending litigation.

“Insurance companies will frequently disagree with physicians as to what is medically necessary,” Stelnicki said. “There are appeals families go through, and you can take things to the state board of insurance, but there’s nothing else you can do.”

The Wealcatches appealed their denial and provided BCBSF with documents, photographs and scans on Logan’s head, the suit said. But BCBSF denied their requests for reimbursement, citing that “expenses for cranial remolding orthosis are excluded from coverage under your policy,” according to the court filing.

Stelnicki said he suspects BCBSF considers plagiocephaly a cosmetic disorder because long-term studies to determine the condition’s effects have not yet been completed. Some medical experts quoted in industry journals say it is a relatively recent phenomenon, heavily connected with the push to decrease sudden infant death syndrome that recommends parents place infants on their back when they sleep.

Several medical journal articles also have made links between plagiocephaly and permanent, severe deformations and neurological dysfunctions.

The Wealcatches’ lawyer, David Durkee, said he hopes the suit addresses the discrepancy between how some insurers and doctors view plagiocephaly.

He said that since he began fighting the case, he has been contacted by anxious parents from all over the country who faced the same resistance from their insurance agencies. The goal of the class action suit is to provide a national precedent, not just a victory for his clients.