Lubeznik v. HealthChicago, Inc.
Appellate Court of Illinois
644 N.E.2d 777 (1994)
Bonnie Lubeznik's (plaintiff's) doctor recommended a specific bone marrow transplant and chemotherapy treatment for her Stage III ovarian cancer and sought pre-certification from her insurer, HealthChicago, Inc. (defendant), whose medical director denied the request as "experimental" before ever obtaining supporting documentation from federal health agencies (which he only gathered afterward). At the hearing, Lubeznik's doctor testified the treatment had a 75 percent complete-remission success rate across 21 prior patients and was not experimental, and Lubeznik's cancer was continuing to spread with poor long-term survival odds absent immediate treatment; the circuit court granted Lubeznik an injunction requiring pre-certification, and HealthChicago appealed.
Whether a health insurance provider may exclude coverage under a policy when the applicable provision is unclear and ambiguous.