Filed 04-26-2021
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`Page 3 of 11
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`FILED
`04-26-2021
`Clerk of Circuit Court
`Waukesha County
`WAUKESHA COUNTY 2021 CV000682
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`Case 2021CV000682
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`Document 2
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`STATE OF WISCONSIN
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`CIRCUIT COURT
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`GEOFFREY D. WILBER
`1900 Highland Drive
`Elm Grove, Wisconsin 53122,
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`MACEE M. WILBER
`1900 Highland Drive
`Elm Grove, Wisconsin 53122,
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`Plaintiffs,
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`v.
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`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,
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`Defendant.
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`Case Code: 30303
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`AMOUNT CLAIMED IS
`GREATER THAN $10,000.00
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`COMPLAINT
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`NOW COMES the Plaintiffs, GEOFFREY D. WILBER and MACEE M. WILBER, by
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`their attorneys, GRUBER LAW OFFICES, LLC, by Attorney Geoffrey D. Wilber and allege as
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`follows:
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`GENERAL ALLEGATIONS APPLICABLE
`TO ALL CLAIMS FOR DAMAGES
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`1.
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`That the Plaintiff, GEOFFREY D. WILBER, is an adult individual residing at 1900
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`Highland Drive, in the Village of Elm Grove, County of Waukesha, State of Wisconsin, 53122.
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`2.
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`That the Plaintiff, MACEE M. WILBER, is an adult individual residing at 1900
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`Highland Drive, in the Village of Elm Grove, County of Waukesha, State of Wisconsin, 53122.
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`3.
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`That the Defendant, ANTHEM BLUE CROSS BLUE SHIELD,
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`is a foreign
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`corporation organized and existing under the laws of the State of Indiana, with its principal offices
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`located at 220 Virginia Avenue, Indianapolis, Indiana, 46204; that Defendant, ANTHEM BLUE
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`CROSS BLUE SHIELD, was at all times material herein, the health insurance carrier of the
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`Plaintiffs, GEOFFREY D. WILBER and MACEE M. WILBER, pursuant to § 803.04(2), Wis.
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`Stats., and is a proper party Defendant by reason of the terms of its policy and the laws of the State
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`of Wisconsin.
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`4.
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`That on or about the 22"" day of December, 2020, the Plaintiffs, GEOFFREY D.
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`WILBER and MACEE M. WILBER, submitted medical bills to the Defendant, ANTHEM BLUE
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`CROSS BLUE SHIELD, on behalf of the Plaintiffs' minor daughter, who had been admitted to a
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`long-term, in-patient medical facility; that payment of the submitted medical bills and all future
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`medical bills associated with the treatment provided by the long-term, in-patient medical facility
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`was denied.
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`FIRST CAUSE OF ACTION: BREACH OF CONTRACT
`AND VIOLATION OF WIS. STAT.§ 628.46 FOR
`GEOFFREY D. WILBER AND MACEE M. WILBER
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`5.
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`Plaintiffs re-allege and incorporate herein, as though more fully set forth herein, all
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`of the allegations contained in paragraphs one (1) through four (4) above with the same force and
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`effect and further alleges as follows.
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`6.
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`At all times material hereto, the insurance policy issued by Defendant, ANTHEM
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`BLUE CROSS BLUE SHIELD,
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`to Plaintiffs, GEOFFREY D. WILBER and MACEE M.
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`WILBER, constituted a contract between the parties and which required Defendant, ANTHEM
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`BLUE CROSS BLUE SHIELD, to make timely payment to Plaintiffs pursuant to § 628.46, Wis.
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`Stats.
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`7.
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`At all
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`times material hereto, Plaintiffs made due demand upon Defendant,
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`ANTHEM BLUE CROSS BLUE SHIELD, through their health insurance coverage, for payment
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`of the medical bills incurred by their minor daughter's admission to a long-term medical facility.
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`8.
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`At all times material hereto, Defendant, ANTHEM BLUE CROSS BLUE SHIELD,
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`failed to issue a response or provide a reasonable basis for its inability to issue a response, within
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`the 30-day timeline as set forth in Wis. Stat. § 628.46.
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`9.
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`At all times material hereto, when Defendant, ANTHEM BLUE CROSS BLUE
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`SHIELD, did issue a response, it denied the claim due to the treatment not being "medically
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`necessary", but failed to disclose the basis of the denial or factors considered supporting the denial,
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`as is require in Wis. Stat. § 628.46.
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`10.
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`Defendant, ANTHEM BLUE CROSS BLUE SHIELD'S, failure to pay constitutes
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`a breach of the insurance contract in question.
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`11.
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`As a direct and proximate result of said breach, Plaintiffs, GEOFFREY D.
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`WILBER and MACEE M. WILBER, have sustained and continue to sustain damages in the
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`amount of the medical bills incurred for the medical care of their minor daughter.
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`12.
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`In addition, Defendant, ANTHEM BLUE CROSS BLUE SHIELD, failure to pay
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`constitutes a violation of Wis. Stat. § 628.46 as such payment is "overdue" entitling Plaintiffs,
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`GEOFFREY D. WILBER and MACEE M. WILBER, to interest in the amount of 12% per annum
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`on the amount due and owing.
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`SECOND CAUSE OF ACTION: BAD FAITH AGAINST PLAINTIFFS,
`GEOFFREY D. WILBER AND MACEE M. WILBER
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`13.
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`Plaintiffs re-allege and incorporate herein, as though more fully set forth herein, all
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`of the allegations contained in paragraphs one (1) through twelve (12) above with the same force
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`and effect and further alleges as follows:
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`14.
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`On or about December 22, 2020, the Plaintiffs, GEOFFREY D. WILBER and
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`MACEE M. WILBER, submitted all information necessary for diligent and good faith evaluation
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`of Plaintiffs' claim to the Defendant, ANTHEM BLUE CROSS BLUE SHIELD, providing written
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`notice of the fact of a covered loss and the amount of loss at that time, and requested payment of
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`the medical bills incurred for the care of their minor daughter.
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`15.
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`On December 23, 2020, Dr. Charlisa Allen, an employee for the Defendant,
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`ANTHEM BLUE CROSS BLUE SHIELD, without speaking to anyone from the long-term care
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`facility, without speaking to any of the minor daughter's prior medical providers, without speaking
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`to the Plaintiffs, GEOFFREY D. WILBER and MACEE M. WILBER, and without seeking any
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`information whatsoever about the prior or current health of the minor daughter, denied coverage
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`stating the treatment was "not medically necessary" and was merely a result of "poor family
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`dynamics" and "acting out behaviors".
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`16.
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`On February 16, 2021, the Plaintiffs, GEOFFREY D. WILBER and MACEE M.
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`WILBER, initiated a written Appeal of Denial of Coverage to the Grievances and Appeals division
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`for the Defendant, ANTHEM BLUE CROSS BLUE SHIELD, seeking a reversal of the original
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`denial of benefits.
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`17.
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`That the February 16, 2021 Appeal included individually written letters from the
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`medical providers previously tasked with caring for the minor daughter, all of whom determined
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`the only option for the safe health and welfare of the Plaintiffs' minor daughter was for her to be
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`placed in a long-term in-patient care facility, that the providers included the minor daughter's long(cid:173)
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`time pediatrician, two mental health therapists, and a pediatric neuropsychologist.
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`18.
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`That on March 24, 2021 Defendant, ANTHEM BLUE CROSS BLUE SHIELD,
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`conducted a telephonic review of the prior claims denial, which included an Appeal Panel
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`comprised of several employees of the Defendant, ANTHEM BLUE CROSS BLUE SHIELD, as
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`well as the Plaintiff, GEOFFREY D. WILBER.
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`19.
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`That during the March 24, 2021 hearing, which started approximately 5 minutes
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`late and was limited to less than 15 minutes, the Anthem Medical Director intimated that the
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`Plaintiffs' minor daughter may not have truly been a risk to harm herself at the time of admission
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`to the long-term facility because the doctor "had several patients who had threatened suicide
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`multiple times but never actually went through with it", suggested the original reviewing doctor,
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`Charlisa Allen, was "simply making an off-handed comment" when she wrote the basis for the
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`original denial of benefits was a result of "poor family dynamics" and "acting out behaviors",
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`before ultimately agreeing to attempt to call
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`the minor daughter's pediatrician, Dr. Megan
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`Hambrook, and primary mental therapist, Maureen Goldblat, to discuss the minor daughter's
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`mental and physical health leading up to the admission to the long-term, in-patient care facility to
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`better determine if the minor daughter's state of mind at the time of admission.
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`20.
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`That on March 25, 2021, Cynthia Gardner, a claims manager for the Defendant,
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`ANTHEM BLUE CROSS BLUE SHIELD, called the Plaintiff, GEOFFREY D. WILBER, and
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`asked him to help her contact the long-term care facility because she had not been able to reach
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`anyone at the facility and stated the appeal would be denied if she was unable to reach someone
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`from the long-term care facility.
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`21.
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`That on March 26, 2021,
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`the Defendant, ANTHEM BLUE CROSS BLUE
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`SHIELD, sent a letter maintaining its previous coverage denial for the medical bills incurred by
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`the Plaintiffs' minor daughter.
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`22.
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`That at no time did the Defendant, ANTHEM BLUE CROSS BLUE SHIELD,
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`attempt to contact the Plaintiffs' minor daughter's pediatrician or primary mental health therapist,
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`as was suggested by the Appeals Panel during the March 24, 2021 hearing; nor did the Defendant
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`ever contact anyone from the current long-term care facility currently caring for the minor
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`daughter, or speak to anyone who has ever met, or spoken with, or provided care for, or provided
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`testing for, or speak to anyone who has made any actual medical diagnoses of the Plaintiffs' minor
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`daughter at any time during either the initial coverage denial or during the appeal of the coverage
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`denial.
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`23.
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`That on April 13, 2021, the Plaintiff, GEOFFREY D. WILBER, called the customer
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`service department to request the file notes documenting the actions taken and decisions made by
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`the Defendant's Appeals Panel, as it relates to the March 24, 2021 telephonic hearing, and any and
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`all subsequent actions taken by the panel; that the first two calls by the Plaintiff resulted in
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`customer service personel hanging up on the Plaintiff after placing him on a long hold; that a third
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`call resulted in the Plaintiff eventually being transferred to a "manager" named Candace McKeller
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`who stated she needed to get approval from her manager before she would be able to email the
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`requested documents to the Plaintiff; that in total, the Plaintiff spent over three (3) hours on the
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`phone attempting to obtain the requested information.
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`24.
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`That on April 14, 2021, Candace McKeller sent the Plaintiff, GEOFFREY D.
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`WILBER, an email asking if anyone had sent him the requested information as discussed on April
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`13, 2021; that the Plaintiff responded that same morning that he had not received any of the
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`requested information; that on April 15, 2012, the Plaintiff, GEOFFREY D. WILBER, again
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`emailed Candace McKeller asking for a status update on the requested information, in-response to
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`the Plaintiff's original request, and in-response to the April 14, 2021 email from Candace
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`McKeller; that on April 19, 2021, a voicemail was left for Candace McKeller asking for a status
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`update; that on April 20, 2021, another email was sent to Candace McKeller asking for a status
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`update; that the Plaintiffs have not received a response to any of the above requests for information
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`or updates to the status of the request for information.
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`25.
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`The actions of the Defendant, ANTHEM BLUE CROSS BLUE SHIELD, by and
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`through the authorized actions of its employees, agents, servants or the like in failing to pay under
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`its health insurance policy constitutes bad faith conduct on the part of the Defendant, and a breach
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`of its fiduciary duty to its insureds for the following, yet not exclusive, reasons:
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`a.
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`There was no reasonable basis for the Defendant, ANTHEM BLUE CROSS BLUE
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`SHIELD, to deny payment or coverage for the Plaintiffs, GEOFFREY D. WILBER and MACEE
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`M. WILBER's, claim in whole or in part for the benefits provided under the policy in question;
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`b.
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`Defendant, ANTHEM BLUE CROSS BLUE SHIELD, did not properly investigate
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`the Plaintiffs, GEOFFREY D. WILBER and MACEE M. WILBER's, claim and/or the
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`investigation was not given reasonable evaluation and review.
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`c.
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`Defendant, ANTHEM BLUE CROSS BLUE SHIELD, did not support the basis of
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`the denial as being "not medically necessary" with any expert medical reports as is required by
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`Wis. Stat. $ 628.46.
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`THIRD CAUSE OF ACTION: PUNITIVE DAMAGES
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`26.
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`Plaintiffs re-allege and incorporate herein, as though more fully set forth herein, all
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`of the allegations contained in paragraphs one (1) through twenty-nine (29) above with the same
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`force and effect.
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`27.
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`Defendant, ANTHEM BLUE CROSS BLUE SHIELD, acted in bad faith
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`intentionally for the purpose of delaying and harassing the Plaintiffs, GEOFFREY D. WILBER
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`and MACEE M. WILBER, to discourage them from asserting their rightful claim and/or to avoid
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`or reduce the payment due Plaintiffs under their medical insurance policy and is subject to punitive
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`damages.
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`28.
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`At all times material hereto, the Plaintiffs, GEOFFREY D. WILBER and MACEE
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`M. WILBER, allege and assert that they are entitled to punitive damages from the Defendant,
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`ANTHEM BLUE CROSS BLUE SHIELD, because the conduct as heretofore alleged constitutes
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`an intentional disregard of their rights.
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`WHEREFORE, the Plaintiffs, GEOFFREY D. WILBER and MACEE M. WILBER,
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`demand judgment against the Defendant, ANTHEM BLUE CROSS BLUE SHIELD, as follows:
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`1.
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`On the First Cause of Action on behalf of the Plaintiffs, GEOFFREY D. WILBER
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`and MACEE M. WILBER, in an amount to be determined by the trier of fact together with the
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`pre-judgment interest, post-judgment interest, costs, actual attorney fees and disbursements of this
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`action;
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`2.
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`On the Second Cause of Action on behalf of the Plaintiffs, GEOFFREY D.
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`WILBER and MACEE M. WILBER, for a determination that the Defendant, ANTHEM BLUE
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`CROSS BLUE SHIELD, violated Wis. Stat. §628.46, and award the Plaintiffs damages in an
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`amount to be determined by the trier of fact together with the pre-judgment interest, post-judgment
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`interest, costs, actual attorney fees and disbursements of this action;
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`3.
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`On the Third Cause of Action on behalf of the Plaintiffs, GEOFFREY D. WILBER
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`and MACEE M. WILBER, be awarded punitive damages against the Defendant, ANTHEM BLUE
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`CROSS BLUE SHIELD, in an amount to be determined by the trier of fact;
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`4.
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`For any and all other relief the Court deems just and equitable.
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`PLAINTIFF HEREBY DEMANDS THAT THE ABOVE ENTITLED
`ACTION BE TRIED BY A JURY OF TWELVE (12) PERSONS
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`Dated at Milwaukee, Wisconsin this 26" day of April, 2021.
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`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:
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`POST OFFICE ADDRESS:
`100 East Wisconsin Avenue, Suite 2800
`Milwaukee, Wisconsin 53202
`Telephone: 414.276.6666
`gdw@gruber-law.com
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