from the Iowa District Court for Polk County, Douglas F.
decedent's estate appeals from a district court review
affirming the denial of health insurance coverage for a vast
majority of an extended hospital stay.
Rebecca A. Brommel of Brown, Winick, Graves, Gross,
Baskerville and Schoenebaum, P.L.C., Des Moines, for
Mitchell R. Kunert of Nyemaster Goode, P.C., Des Moines, for
by Vaitheswaran, P.J., and Potterfield and Tabor, JJ.
VAITHESWARAN, PRESIDING JUDGE.
retired University of Iowa employee sought coverage from his
health insurance plan for an extended hospital stay in South
Korea. This appeal flows from the denial of coverage for the
vast majority of his hospitalization.
Background Facts and Proceedings
Rim was enrolled in the UIChoice Retiree group health plan,
sponsored and funded by the University of Iowa and
administered by Wellmark Blue Cross and Blue Shield of Iowa
(Wellmark). He fell in his South Korean apartment and was
hospitalized for more than a year.
filed a claim with Wellmark for hospital services provided
between October 8, 2014, and December 4, 2015. Wellmark
concluded the services received from January 1, 2015, through
December 4, 2015, were "considered long term care and
custodial care," which were "not covered" by
sought external review. See Iowa Code ch. 514J
(2016) (governing "External Review of Health Care
Coverage Decisions"); see also id. §
514J.105 ("A covered person or the covered person's
authorized representative may make a request for an external
review of a final adverse determination."). An
independent review organization (IRO) approved by the Iowa
Insurance Commissioner evaluated the medical records from the
South Korean hospital and found certain "clinical
records" were "largely illegible as they [were]
written in Korean font" and "[t]he format of the
records [was] difficult to determine, and the headings of the
sections of the documentation were not translated." The
IRO overturned Wellmark's denial of coverage from January
1, 2015, through January 31, 2015, but affirmed the denial of
coverage for the balance of Rim's hospitalization,
reasoning the stay was medically unnecessary.
filed a petition for judicial review. See id. §
514J.110(2)(a) (authorizing petitions for judicial review of
external review decisions). Rim cited the judicial review
standards of Iowa Code chapter 17A, governing review of
agency action. Wellmark answered and denied "the alleged
applicability of Iowa Code Chapter 17A." Meanwhile, Rim
passed away, and his estate was substituted as a
district court declined to apply the judicial review
standards of chapter 17A. The court next addressed Rim's
concern with the IRO's inability to decipher certain
records and concluded there was "nothing in the law that
required Wellmark to have Rim's medical records
translated into English." Finally, the court affirmed
the IRO's determination that the bulk of the hospital
stay was medically unnecessary. Rim appealed.
Applicability of ...