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    FLORIDA - June 4, 2018 - Shari Gerson and Greg P. Durham, Sr. defended a major health insurer at a bench trial in Brevard County and obtained a final judgment in our client's favor. The issue at trial was whether the insurer improperly denied the plaintiff coverage for a multi-level spine fusion surgery under the benefits plan provided by his employer, a local municipality. The policy contained an exclusion for any procedure that is unproven to treat the condition for which it is sought to be performed. The insurer's denial was based on its medical director's conclusion (after peer-to-peer consultation with plaintiff's surgeon and reliance on current clinical studies containing level-one data) that the multi-level fusion procedure was unproven for the specific condition diagnosed in the plaintiff, i.e., degenerative disc disease without instability.

    After a one-day trial and presentation of written closing arguments, the Court found that our client insurer's policy exclusion was unambiguous. While there exists controversy whether the fusion surgery is effective for plaintiff's condition, our client's medical director had a reasonable basis for the denial, based upon his education, experience and training and the current medical literature. Notwithstanding, the insurer does not have unfettered discretion in coverage decisions. The court found the plaintiff did not show, by the greater weight of the evidence, that the procedure was covered for his condition. Finally, the Court found the plaintiff's condition was covered, but this particular procedure was not covered for his condition. However, other procedures would be covered for the plaintiff's condition, including a laminectomy or discectomy. The trial team also consisted of Shayna A. Freyman, Lesley-Anne Marks, Shauna Capi, Athena Sasso, Amy Vasilievish and Jodi Aliano.

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