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Estate of Rim v. Wellmark, Inc.

Court of Appeals of Iowa

June 19, 2019

ESTATE OF KWAN RIM, Plaintiff-Appellant,
v.
WELLMARK, INC. d/b/a WELLMARK BLUE CROSS AND BLUE SHIELD OF IOWA and WELLMARK HEALTH PLAN OF IOWA, INC., Defendants-Appellees.

          Appeal from the Iowa District Court for Polk County, Douglas F. Staskal, Judge.

         A 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. AFFIRMED.

          Rebecca A. Brommel of Brown, Winick, Graves, Gross, Baskerville and Schoenebaum, P.L.C., Des Moines, for appellant.

          Mitchell R. Kunert of Nyemaster Goode, P.C., Des Moines, for appellees.

          Heard by Vaitheswaran, P.J., and Potterfield and Tabor, JJ.

          VAITHESWARAN, PRESIDING JUDGE.

         A 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.

         I. Background Facts and Proceedings

         Kwan 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.

         Rim 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 his plan.

         Rim 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)[1] approved by the Iowa Insurance Commissioner[2] 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.

         Rim 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 party.[3]

         The 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.

         II. Applicability of ...


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