Fill and Sign the Insurer Claim Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) COMPLAINT COMES NOW _______________, Plaintiff, and files this complaint against the Defendant, _______________, and for cause of action would show unto the Court the following, to wit: I. That _______________ and ______________ are both adult resident citizens of ____________ County, ________________. The Defendant, ______________, is a ______________ corporation with its principal place of business being located at ______________, _______________. Service of process may be served upon the Defendant by serving its president, ______________, ______________, _______________. II. Plaintiff, ______________, would show that he purchased a policy of hospital insurance from the Defendant bearing contract number ______________. That said insurance policy had an effective date of the ______ day of _____________, 20___. Plaintiffs would further show - 1 - that at all times herein complained of the premium on said policy was paid in full. III. On or about the ____ day of ___________, 20____, ______________ sustained an injury when she sat down on a box that had been left in her car. Plaintiff ______________ was experiencing severe pain and went to the emergency room of the _______________ Hospital in _______________, _______________ where she was treated and released. Plaintiffs would further show that on or about the ______ day of ______________, 20___, _______________ was still suffering extreme pain in the coccygeal area and went to see Dr. ______________ in _______________, _______________. Dr. ______________ admitted ______________ to the _______________ on the ____ day of ____________, 20____, where she was confined until the ______ day of ____________, 20___. IV. Plaintiff was still undergoing extreme pain in the coccygeal area on or about the _____ day of ____________, 20____, and she went to see her family physician, Dr. ______________, in _______________, _______________. Dr. ______________ immediately hospitalized ______________ in the _______________ Daughters Hospital in _______________, _______________ where she was confined until the ______ day of _____________, 20____. V. Plaintiffs would show that claims were submitted to the Defendant for the aforesaid hospital confinements and doctor bills. The defendant paid the claims with the exception of the claim from the _______________ Hospital for ______________ ordered and medically necessary confinement from the ____ day of ____________, 20___, to the _____ day of _____________, 20___. - 2 - VI. Plaintiffs would show that the Defendant paid the claim to Dr. ______________, ______________'s attending physician who ordered her hospital stay in the _______________ Hospital but refused to pay said hospital claim in the amount of $_______________. Plaintiffs would further show that a pre-certification of ______________'s hospitalization was obtained from the Defendant. VII. Plaintiff ______________ contacted the Defendant on several occasions concerning their non-payment of her hospital claim and was led to believe that the claim would be paid. Finally on the ____ day of ____________, 20____, six months after her hospital confinement to the _______________ Hospital, Plaintiffs received a letter from the Defendant signed by ______________, legal counsel, stating that an outside consulting physician's opinion was that her hospitalization was not medically necessary. VIII. Plaintiffs would show that ______________ was admitted to _______________ Hospital upon the orders of Dr. ______________, a licensed physician in the State of _______________. ______________ was not physically seen by the defendant's outside consulting physician. WHEREFORE, PREMISES CONSIDERED, Plaintiff demands judgment of and from the Defendant in the amount of $_______________ actual damages and $_______________ punitive damages for the willful, wanton and malicious actions of the Defendant in refusing to pay Plaintiff ______________'s just and medically necessary hospital confinement claim to the _______________ Hospital. - 3 - Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: CERTIFICATE OF SERVICE I, ______________________________, do hereby certify that I have this day mailed, U.S. Mail, postage prepaid, a true and correct copy of the above and foregoing to __________________________________, at the following address; ___________________________________________________________________ THIS the ____ day of _____________, 20____. _________________________________ _______ - 4 -