The law firm of Gianelli & Morris has filed individual and class action complaints against UnitedHealthcare of California alleging the wrongful denial of coverage for the Coflex medical device to treat the plaintiffs’ spinal stenosis and back pain.

On November 4, 2020, the California insurance law firm Gianelli & Morris filed individual and class action complaints in the Superior Court of the State of California for the County of San Luis Obispo. The case is titled Matthew Kobliska and Peter Riegelhuth v. UHC of California, also known as UnitedHealthcare of California (Case No. 20CV-0571). The individual complaints in the lawsuit allege breach of contract and breach of the implied covenant of good faith and fair dealing (bad faith), while the class action complaint alleges violations of California Business & Professions Code Section 17200 and seeks declaratory relief.

The complaint alleges that UHC of California wrongfully denies coverage requests to use an interlaminar stabilization device called Coflex to treat lumbar spinal stenosis and the back and leg pain associated with this debilitating condition. UHC of California’s internal coverage guidelines state that Coflex is “unproven and not medically necessary due to insufficient evidence of efficacy” and therefore should not be covered by insurance. In contrast, the complaint alleges that Coflex is FDA-approved as safe and effective and has been proven as such by multiple clinical studies. According to the complaint, Coflex is widely recommended by spine surgeons and has been successfully used to treat spinal stenosis for years.

Because UHC of California issues blanket denials of all coverage requests for Coflex without regard for the individual policyholder’s medical condition, need or qualification for the device, and based on the evidence cited in the complaint regarding the proven nature of Coflex, plaintiffs allege that UHC of California’s systematic denials amount to unfair business practices. The complaint further alleges these denials are made in bad faith without a valid reason and based on information known by the insurer to be erroneous.

The lawsuit is seeking a declaratory judgment by the court whether UHC of California’s blanket denials are wrong. The lawsuit further seeks special and general damages, punitive damages, costs of the lawsuit, and other relief the court will deem just and proper. According to plaintiffs’ attorney Robert Gianelli, "Surgery with Coflex provides a substantial benefit to patients suffering from spinal stenosis. Health insurance companies that deny their policyholders this valuable treatment are acting in their own financial interests and contrary to the policyholders' medical needs."

The lawsuit is seeking certification of a class of plaintiffs including all UHC of California members whose claims for treatment with Coflex interlaminar stabilization were denied as unproven and not medically necessary pursuant to the health plan’s Medical Policy for Surgical Treatment of Spine Pain at any time during the applicable statute of limitations. Individuals interested to know whether they may be members of the class can contact the Gianelli & Morris law firm at 866-821-4104. The firm is also looking into similar cases involving other insurance companies.

About Gianelli & Morris

Gianelli & Morris is a Los-Angeles based insurance law firm concentrating its practice on the representation of California insurance policyholders who have been improperly denied insurance benefits.