Opinion ID: 2803276
Heading Depth: 2
Heading Rank: 3

Heading: Plaintiff Faison’s Plan Claim

Text: Between October 2009 and June 2010, in a series of Explanation of Benefits statements sent to Faison, Paragon denied benefits on the basis that the medical care related to his July 26, 2009 accident was not covered under the terms of the Plan. On August 10, 2010, Faison appealed the denial to the Hospital and requested that Paragon provide additional information concerning the grounds for its denial. On September 14, 2010, Paragon sent a letter explaining that it had denied coverage based on the Plan’s “Illegal Acts” exclusion. The “Plan Exclusions” section provides that, “[f]or all Medical Benefits shown in the Schedule of Benefits, a charge for the following is not covered”: 4 Case: 14-14939 Date Filed: 05/26/2015 Page: 5 of 14 (19) Illegal acts. Charges for services received as a result of Injury or Sickness occurring directly or indirectly, as a result of a Serious Illegal Act, or a riot or public disturbance. For purposes of this exclusion, the term “Serious Illegal Act” shall mean any act or series of acts that, if prosecuted as a criminal offense, a sentence to a term of imprisonment in excess of one year could be imposed. It is not necessary that criminal charges be filed, or, if filed, that a conviction result, or that a sentence of imprisonment for a term in excess of one year be imposed for this exclusion to apply. (Emphasis added). In an October 21, 2010 letter, the Hospital informed Faison that the Committee affirmed the denial of his claim based on the “Illegal Acts” exclusion.