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Filed 04-26-2021
`
`Page 3 of 11
`
`FILED
`04-26-2021
`Clerk of Circuit Court
`Waukesha County
`WAUKESHA COUNTY 2021 CV000682
`
`Case 2021CV000682
`
`Document 2
`
`STATE OF WISCONSIN
`
`CIRCUIT COURT
`
`GEOFFREY D. WILBER
`1900 Highland Drive
`Elm Grove, Wisconsin 53122,
`
`MACEE M. WILBER
`1900 Highland Drive
`Elm Grove, Wisconsin 53122,
`
`Plaintiffs,
`
`v.
`
`ANTHEM BLUE CROSS BLUE SHIELD
`220 Virginia Avenue
`Indianapolis, Indiana 46204
`Registered Agent: CT Corporate Systems
`301 South Bedford Street
`Suite 1
`Madison, Wisconsin 53703,
`
`Defendant.
`
`Case Code: 30303
`
`AMOUNT CLAIMED IS
`GREATER THAN $10,000.00
`
`COMPLAINT
`
`NOW COMES the Plaintiffs, GEOFFREY D. WILBER and MACEE M. WILBER, by
`
`their attorneys, GRUBER LAW OFFICES, LLC, by Attorney Geoffrey D. Wilber and allege as
`
`follows:
`
`GENERAL ALLEGATIONS APPLICABLE
`TO ALL CLAIMS FOR DAMAGES
`
`1.
`
`That the Plaintiff, GEOFFREY D. WILBER, is an adult individual residing at 1900
`
`Highland Drive, in the Village of Elm Grove, County of Waukesha, State of Wisconsin, 53122.
`
`2.
`
`That the Plaintiff, MACEE M. WILBER, is an adult individual residing at 1900
`
`Highland Drive, in the Village of Elm Grove, County of Waukesha, State of Wisconsin, 53122.
`
`Case 2:21-cv-00688-SCD Filed 06/03/21 Page 1 of 9 Document 1-1
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`Page 13
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`

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`Case 2021CV000682
`
`Document 2
`
`Filed 04-26-2021
`
`Page 4 of 11
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`3.
`
`That the Defendant, ANTHEM BLUE CROSS BLUE SHIELD,
`
`is a foreign
`
`corporation organized and existing under the laws of the State of Indiana, with its principal offices
`
`located at 220 Virginia Avenue, Indianapolis, Indiana, 46204; that Defendant, ANTHEM BLUE
`
`CROSS BLUE SHIELD, was at all times material herein, the health insurance carrier of the
`
`Plaintiffs, GEOFFREY D. WILBER and MACEE M. WILBER, pursuant to § 803.04(2), Wis.
`
`Stats., and is a proper party Defendant by reason of the terms of its policy and the laws of the State
`
`of Wisconsin.
`
`4.
`
`That on or about the 22"" day of December, 2020, the Plaintiffs, GEOFFREY D.
`
`WILBER and MACEE M. WILBER, submitted medical bills to the Defendant, ANTHEM BLUE
`
`CROSS BLUE SHIELD, on behalf of the Plaintiffs' minor daughter, who had been admitted to a
`
`long-term, in-patient medical facility; that payment of the submitted medical bills and all future
`
`medical bills associated with the treatment provided by the long-term, in-patient medical facility
`
`was denied.
`
`FIRST CAUSE OF ACTION: BREACH OF CONTRACT
`AND VIOLATION OF WIS. STAT.§ 628.46 FOR
`GEOFFREY D. WILBER AND MACEE M. WILBER
`
`5.
`
`Plaintiffs re-allege and incorporate herein, as though more fully set forth herein, all
`
`of the allegations contained in paragraphs one (1) through four (4) above with the same force and
`
`effect and further alleges as follows.
`
`6.
`
`At all times material hereto, the insurance policy issued by Defendant, ANTHEM
`
`BLUE CROSS BLUE SHIELD,
`
`to Plaintiffs, GEOFFREY D. WILBER and MACEE M.
`
`WILBER, constituted a contract between the parties and which required Defendant, ANTHEM
`
`BLUE CROSS BLUE SHIELD, to make timely payment to Plaintiffs pursuant to § 628.46, Wis.
`
`Stats.
`
`Case 2:21-cv-00688-SCD Filed 06/03/21 Page 2 of 9 Document 1-1
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`Page 14
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`

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`Case 2021CV000682
`
`Document 2
`
`Filed 04-26-2021
`
`Page 5 of 11
`
`7.
`
`At all
`
`times material hereto, Plaintiffs made due demand upon Defendant,
`
`ANTHEM BLUE CROSS BLUE SHIELD, through their health insurance coverage, for payment
`
`of the medical bills incurred by their minor daughter's admission to a long-term medical facility.
`
`8.
`
`At all times material hereto, Defendant, ANTHEM BLUE CROSS BLUE SHIELD,
`
`failed to issue a response or provide a reasonable basis for its inability to issue a response, within
`
`the 30-day timeline as set forth in Wis. Stat. § 628.46.
`
`9.
`
`At all times material hereto, when Defendant, ANTHEM BLUE CROSS BLUE
`
`SHIELD, did issue a response, it denied the claim due to the treatment not being "medically
`
`necessary", but failed to disclose the basis of the denial or factors considered supporting the denial,
`
`as is require in Wis. Stat. § 628.46.
`
`10.
`
`Defendant, ANTHEM BLUE CROSS BLUE SHIELD'S, failure to pay constitutes
`
`a breach of the insurance contract in question.
`
`11.
`
`As a direct and proximate result of said breach, Plaintiffs, GEOFFREY D.
`
`WILBER and MACEE M. WILBER, have sustained and continue to sustain damages in the
`
`amount of the medical bills incurred for the medical care of their minor daughter.
`
`12.
`
`In addition, Defendant, ANTHEM BLUE CROSS BLUE SHIELD, failure to pay
`
`constitutes a violation of Wis. Stat. § 628.46 as such payment is "overdue" entitling Plaintiffs,
`
`GEOFFREY D. WILBER and MACEE M. WILBER, to interest in the amount of 12% per annum
`
`on the amount due and owing.
`
`SECOND CAUSE OF ACTION: BAD FAITH AGAINST PLAINTIFFS,
`GEOFFREY D. WILBER AND MACEE M. WILBER
`
`13.
`
`Plaintiffs re-allege and incorporate herein, as though more fully set forth herein, all
`
`of the allegations contained in paragraphs one (1) through twelve (12) above with the same force
`
`and effect and further alleges as follows:
`
`Case 2:21-cv-00688-SCD Filed 06/03/21 Page 3 of 9 Document 1-1
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`Page 15
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`

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`Case 2021CV000682
`
`Document 2
`
`Filed 04-26-2021
`
`Page 6 of 11
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`14.
`
`On or about December 22, 2020, the Plaintiffs, GEOFFREY D. WILBER and
`
`MACEE M. WILBER, submitted all information necessary for diligent and good faith evaluation
`
`of Plaintiffs' claim to the Defendant, ANTHEM BLUE CROSS BLUE SHIELD, providing written
`
`notice of the fact of a covered loss and the amount of loss at that time, and requested payment of
`
`the medical bills incurred for the care of their minor daughter.
`
`15.
`
`On December 23, 2020, Dr. Charlisa Allen, an employee for the Defendant,
`
`ANTHEM BLUE CROSS BLUE SHIELD, without speaking to anyone from the long-term care
`
`facility, without speaking to any of the minor daughter's prior medical providers, without speaking
`
`to the Plaintiffs, GEOFFREY D. WILBER and MACEE M. WILBER, and without seeking any
`
`information whatsoever about the prior or current health of the minor daughter, denied coverage
`
`stating the treatment was "not medically necessary" and was merely a result of "poor family
`
`dynamics" and "acting out behaviors".
`
`16.
`
`On February 16, 2021, the Plaintiffs, GEOFFREY D. WILBER and MACEE M.
`
`WILBER, initiated a written Appeal of Denial of Coverage to the Grievances and Appeals division
`
`for the Defendant, ANTHEM BLUE CROSS BLUE SHIELD, seeking a reversal of the original
`
`denial of benefits.
`
`17.
`
`That the February 16, 2021 Appeal included individually written letters from the
`
`medical providers previously tasked with caring for the minor daughter, all of whom determined
`
`the only option for the safe health and welfare of the Plaintiffs' minor daughter was for her to be
`
`placed in a long-term in-patient care facility, that the providers included the minor daughter's long(cid:173)
`
`time pediatrician, two mental health therapists, and a pediatric neuropsychologist.
`
`18.
`
`That on March 24, 2021 Defendant, ANTHEM BLUE CROSS BLUE SHIELD,
`
`conducted a telephonic review of the prior claims denial, which included an Appeal Panel
`
`Case 2:21-cv-00688-SCD Filed 06/03/21 Page 4 of 9 Document 1-1
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`Page 16
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`

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`Case 2021 CV000682
`
`Document 2
`
`Filed 04-26-2021
`
`Page 7 of 11
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`comprised of several employees of the Defendant, ANTHEM BLUE CROSS BLUE SHIELD, as
`
`well as the Plaintiff, GEOFFREY D. WILBER.
`
`19.
`
`That during the March 24, 2021 hearing, which started approximately 5 minutes
`
`late and was limited to less than 15 minutes, the Anthem Medical Director intimated that the
`
`Plaintiffs' minor daughter may not have truly been a risk to harm herself at the time of admission
`
`to the long-term facility because the doctor "had several patients who had threatened suicide
`
`multiple times but never actually went through with it", suggested the original reviewing doctor,
`
`Charlisa Allen, was "simply making an off-handed comment" when she wrote the basis for the
`
`original denial of benefits was a result of "poor family dynamics" and "acting out behaviors",
`
`before ultimately agreeing to attempt to call
`
`the minor daughter's pediatrician, Dr. Megan
`
`Hambrook, and primary mental therapist, Maureen Goldblat, to discuss the minor daughter's
`
`mental and physical health leading up to the admission to the long-term, in-patient care facility to
`
`better determine if the minor daughter's state of mind at the time of admission.
`
`20.
`
`That on March 25, 2021, Cynthia Gardner, a claims manager for the Defendant,
`
`ANTHEM BLUE CROSS BLUE SHIELD, called the Plaintiff, GEOFFREY D. WILBER, and
`
`asked him to help her contact the long-term care facility because she had not been able to reach
`
`anyone at the facility and stated the appeal would be denied if she was unable to reach someone
`
`from the long-term care facility.
`
`21.
`
`That on March 26, 2021,
`
`the Defendant, ANTHEM BLUE CROSS BLUE
`
`SHIELD, sent a letter maintaining its previous coverage denial for the medical bills incurred by
`
`the Plaintiffs' minor daughter.
`
`22.
`
`That at no time did the Defendant, ANTHEM BLUE CROSS BLUE SHIELD,
`
`attempt to contact the Plaintiffs' minor daughter's pediatrician or primary mental health therapist,
`
`Case 2:21-cv-00688-SCD Filed 06/03/21 Page 5 of 9 Document 1-1
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`Page 17
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`

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`Case 2021 CV000682
`
`Document 2
`
`Filed 04-26-2021
`
`Page 8 of 11
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`as was suggested by the Appeals Panel during the March 24, 2021 hearing; nor did the Defendant
`
`ever contact anyone from the current long-term care facility currently caring for the minor
`
`daughter, or speak to anyone who has ever met, or spoken with, or provided care for, or provided
`
`testing for, or speak to anyone who has made any actual medical diagnoses of the Plaintiffs' minor
`
`daughter at any time during either the initial coverage denial or during the appeal of the coverage
`
`denial.
`
`23.
`
`That on April 13, 2021, the Plaintiff, GEOFFREY D. WILBER, called the customer
`
`service department to request the file notes documenting the actions taken and decisions made by
`
`the Defendant's Appeals Panel, as it relates to the March 24, 2021 telephonic hearing, and any and
`
`all subsequent actions taken by the panel; that the first two calls by the Plaintiff resulted in
`
`customer service personel hanging up on the Plaintiff after placing him on a long hold; that a third
`
`call resulted in the Plaintiff eventually being transferred to a "manager" named Candace McKeller
`
`who stated she needed to get approval from her manager before she would be able to email the
`
`requested documents to the Plaintiff; that in total, the Plaintiff spent over three (3) hours on the
`
`phone attempting to obtain the requested information.
`
`24.
`
`That on April 14, 2021, Candace McKeller sent the Plaintiff, GEOFFREY D.
`
`WILBER, an email asking if anyone had sent him the requested information as discussed on April
`
`13, 2021; that the Plaintiff responded that same morning that he had not received any of the
`
`requested information; that on April 15, 2012, the Plaintiff, GEOFFREY D. WILBER, again
`
`emailed Candace McKeller asking for a status update on the requested information, in-response to
`
`the Plaintiff's original request, and in-response to the April 14, 2021 email from Candace
`
`McKeller; that on April 19, 2021, a voicemail was left for Candace McKeller asking for a status
`
`update; that on April 20, 2021, another email was sent to Candace McKeller asking for a status
`
`Case 2:21-cv-00688-SCD Filed 06/03/21 Page 6 of 9 Document 1-1
`
`Page I 8
`
`

`

`Case 2021 CV000682
`
`Document 2
`
`Filed 04-26-2021
`
`Page 9 of 11
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`update; that the Plaintiffs have not received a response to any of the above requests for information
`
`or updates to the status of the request for information.
`
`25.
`
`The actions of the Defendant, ANTHEM BLUE CROSS BLUE SHIELD, by and
`
`through the authorized actions of its employees, agents, servants or the like in failing to pay under
`
`its health insurance policy constitutes bad faith conduct on the part of the Defendant, and a breach
`
`of its fiduciary duty to its insureds for the following, yet not exclusive, reasons:
`
`a.
`
`There was no reasonable basis for the Defendant, ANTHEM BLUE CROSS BLUE
`
`SHIELD, to deny payment or coverage for the Plaintiffs, GEOFFREY D. WILBER and MACEE
`
`M. WILBER's, claim in whole or in part for the benefits provided under the policy in question;
`
`b.
`
`Defendant, ANTHEM BLUE CROSS BLUE SHIELD, did not properly investigate
`
`the Plaintiffs, GEOFFREY D. WILBER and MACEE M. WILBER's, claim and/or the
`
`investigation was not given reasonable evaluation and review.
`
`c.
`
`Defendant, ANTHEM BLUE CROSS BLUE SHIELD, did not support the basis of
`
`the denial as being "not medically necessary" with any expert medical reports as is required by
`
`Wis. Stat. $ 628.46.
`
`THIRD CAUSE OF ACTION: PUNITIVE DAMAGES
`
`26.
`
`Plaintiffs re-allege and incorporate herein, as though more fully set forth herein, all
`
`of the allegations contained in paragraphs one (1) through twenty-nine (29) above with the same
`
`force and effect.
`
`27.
`
`Defendant, ANTHEM BLUE CROSS BLUE SHIELD, acted in bad faith
`
`intentionally for the purpose of delaying and harassing the Plaintiffs, GEOFFREY D. WILBER
`
`and MACEE M. WILBER, to discourage them from asserting their rightful claim and/or to avoid
`
`Case 2:21-cv-00688-SCD Filed 06/03/21 Page 7 of 9 Document 1-1
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`Page 19
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`

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`Case 2021CV000682
`
`Document 2
`
`Filed 04-26-2021
`
`Page 10 of 11
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`or reduce the payment due Plaintiffs under their medical insurance policy and is subject to punitive
`
`damages.
`
`28.
`
`At all times material hereto, the Plaintiffs, GEOFFREY D. WILBER and MACEE
`
`M. WILBER, allege and assert that they are entitled to punitive damages from the Defendant,
`
`ANTHEM BLUE CROSS BLUE SHIELD, because the conduct as heretofore alleged constitutes
`
`an intentional disregard of their rights.
`
`WHEREFORE, the Plaintiffs, GEOFFREY D. WILBER and MACEE M. WILBER,
`
`demand judgment against the Defendant, ANTHEM BLUE CROSS BLUE SHIELD, as follows:
`
`1.
`
`On the First Cause of Action on behalf of the Plaintiffs, GEOFFREY D. WILBER
`
`and MACEE M. WILBER, in an amount to be determined by the trier of fact together with the
`
`pre-judgment interest, post-judgment interest, costs, actual attorney fees and disbursements of this
`
`action;
`
`2.
`
`On the Second Cause of Action on behalf of the Plaintiffs, GEOFFREY D.
`
`WILBER and MACEE M. WILBER, for a determination that the Defendant, ANTHEM BLUE
`
`CROSS BLUE SHIELD, violated Wis. Stat. §628.46, and award the Plaintiffs damages in an
`
`amount to be determined by the trier of fact together with the pre-judgment interest, post-judgment
`
`interest, costs, actual attorney fees and disbursements of this action;
`
`3.
`
`On the Third Cause of Action on behalf of the Plaintiffs, GEOFFREY D. WILBER
`
`and MACEE M. WILBER, be awarded punitive damages against the Defendant, ANTHEM BLUE
`
`CROSS BLUE SHIELD, in an amount to be determined by the trier of fact;
`
`4.
`
`For any and all other relief the Court deems just and equitable.
`
`PLAINTIFF HEREBY DEMANDS THAT THE ABOVE ENTITLED
`ACTION BE TRIED BY A JURY OF TWELVE (12) PERSONS
`
`Case 2:21-cv-00688-SCD Filed 06/03/21 Page 8 of 9 Document 1-1
`
`Page 110
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`

`

`Case 2021CV000682
`
`Document 2
`
`Filed 04-26-2021
`
`Page 11 of 11
`
`Dated at Milwaukee, Wisconsin this 26" day of April, 2021.
`
`GRUBER LAW OFFICES, LLC
`Attorneys for Plaintiffs, GEOFFREY D. WILBER
`and MACEE M. WILBER, a Minor by his guardian
`ad litem, Geoffrey D. Wilber
`
`Isl Geoffrey D. Wilber
`Geoffrey D. Wilber
`SBN: 1041500
`
`By:
`
`POST OFFICE ADDRESS:
`100 East Wisconsin Avenue, Suite 2800
`Milwaukee, Wisconsin 53202
`Telephone: 414.276.6666
`gdw@gruber-law.com
`
`Case 2:21-cv-00688-SCD Filed 06/03/21 Page 9 of 9 Document 1-1
`
`Page 111
`
`

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