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McElroy v. Connecticut General Life Insurance Company

Court of Appeals of Tennessee, Knoxville

December 12, 2019

KENNETH RAY McELROY et al.
v.
CONNECTICUT GENERAL LIFE INSURANCE COMPANY et al.

          Session January 15, 2019

          Appeal from the Circuit Court for Hamilton County No. 15C1479 Ward Jeffrey Hollingsworth, Judge

         An insured sued for breach of contract after his insurance company denied payment for a surgical procedure. The insurance company moved for summary judgment, arguing that the insured could not establish a breach of contract because the procedure was excluded from coverage in the medical benefits plan. The trial court granted summary judgment to the insurance company and dismissed the complaint. Because the insurance company was 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 Circuit Court Affirmed

          Kent T. Jones, Cleveland, Tennessee, for the appellants, Kenneth Ray McElroy and Janet McElroy.

          D. Scott Bennett and Mary C. DeCamp, Chattanooga, Tennessee, for the appellees, Connecticut General Life Insurance Company d/b/a Cigna Healthcare, Inc. and John Does.

          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.

         On June 18, 2013, Kenneth Ray McElroy had a 50-pound growth removed from his abdominal region. Mr. McElroy was covered by a medical benefits plan provided by the Hamilton County Department of Education. After his surgeon's claim for payment was denied, Mr. McElroy and his wife filed suit against Connecticut General Life Insurance Company ("Cigna"), the third-party administrator of the plan, and others in the Circuit Court for Hamilton County, Tennessee, seeking damages for breach of contract and various torts.

         According to the complaint, Mr. McElroy's lower abdomen began to swell after he began a new diabetes treatment in 2006. By 2012, the growth weighed approximately fifty pounds and extended to his knees. The excess weight adversely impacted his back and lower extremities. He also developed skin infections in the affected area. Antibiotic treatments provided only temporary relief. Recurrent infections led to multiple areas of dead tissue. Due to his physical condition, he was unable to work or enjoy time with family.

         His physicians recommended surgical removal of the excess growth. But Cigna refused several preauthorization requests for the recommended procedure. Cigna maintained that the medical benefits plan excluded payment for a panniculectomy, the medical term for the requested procedure. So his physicians continued to treat him with antibiotics, albeit with limited success.

         In 2013, his physicians reconsidered surgical options. Dr. Vincente Mejia determined that a panniculectomy was necessary to treat his recurrent infections. Dr. Mejia described a panniculectomy as the "removal of a large amount of the pannus, which is basically . . . [o]vergrowth of the skin and subcutaneous tissues in the lower abdomen." On June 18, 2013, Dr. ...


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