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Miller v. TRH Health Insurance Co.

Court of Appeals of Tennessee, Knoxville

October 2, 2019

GEORGE E. MILLER ET AL.
v.
TRH HEALTH INSURANCE COMPANY ET AL.

          Session January 15, 2019

          Appeal from the Chancery Court for Sevier County No. 16-11-368 Telford E. Forgety, Jr., Chancellor

         An insured sued his health insurance provider, seeking damages for breach of contract and bad faith refusal to pay valid insurance claims after coverage was denied for medical expenses related to the removal of a kidney stone. The defendants moved for summary judgment based on a benefit exclusion rider to the insurance contract that excluded coverage for treatment, surgery, or expenses related to kidney stones. The trial court rejected the insured's argument that the exclusion rider did not apply and granted summary judgment to the defendants. Because the defendants were entitled to a judgment of dismissal as a matter of law based on the undisputed facts, we affirm.

         Tenn. R. App. P. 3 Appeal as of Right; Judgment of the Chancery Court Affirmed

          Douglas E. Taylor, Seymour, Tennessee, for the appellants, George E. Miller and Donna Miller.

          Thomas L. Kilday, Greeneville, Tennessee, for the appellees, TRH Health Insurance Company and BlueCross BlueShield of Tennessee, Inc.

          W. Neal McBrayer, J., delivered the opinion of the court, in which Charles D. Susano, Jr. and Thomas R. Frierson II, JJ., joined.

          OPINION

          W. NEAL MCBRAYER, JUDGE

         I.

         A.

         In October 2012, George Miller developed a fever with severe abdominal pain. His primary care physician, Dr. Steven Johnson, initially treated him with IV fluids for dehydration. Tests later revealed Mr. Miller was suffering from both a staph infection and a 2.5 centimeter kidney stone. So Dr. Johnson referred Mr. Miller to Dr. Paul Hatcher, a urologist, for treatment.

         Dr. Hatcher diagnosed Mr. Miller with a recurrent right renal stone. He recommended lithotripsy to remove the kidney stone and blood work. Before the kidney stone was removed, Dr. Hatcher prescribed antibiotics and ordered the insertion of a drainage tube. Dr. Hatcher then removed the kidney stone using percutaneous ultrasonic lithotripsy. Mr. Miller tolerated the procedure well and was released from Dr. Hatcher's care by the beginning of November.

         Mr. Miller had health insurance through the Tennessee Rural Health Improvement Association ("TRH"). The health insurance contract included a benefit exclusion rider specific to Mr. Miller. Based on his previous history, the rider excluded coverage for "any treatment, surgery or expenses relating to kidney stone, gravel or colic of the urinary system" for seven years.

         Following Mr. Miller's treatment, his health care providers submitted claims for payment of medical expenses. Citing the benefit exclusion rider, TRH refused to pay any claims for medical expenses associated with treatment ...


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