Fill and Sign the Mississippi Motor Vehicle 497315355 Form

IN THE CIRCUIT COURT OF       COUNTY, MISSISSIPPI       AND       PLAINTIFFS VS. NO.             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, Mississippi. The Defendant,       , is a Mississippi corporation with its principal place of business being located at       ,       , Mississippi. Service of process may be served upon the Defendant by serving its president,       ,       ,       , Mississippi. II. Plaintiff,       , would show that he/she purchased a policy of hospital insurance from the Defendant bearing contract number       . That said insurance policy had an effective date of             ,       . Plaintiffs would further show that at all times herein complained of the premium on said policy was paid in full. III. On or about             ,       ,       sustained an injury when he/she sat down on a box that had been left in his/her car. Plaintiff       was experiencing severe pain and went to the emergency room of the       in       , Mississippi where he/she was treated and released. Plaintiffs would further show that on or about             ,             was still suffering extreme pain in the coccygeal area and went to see       in       , Mississippi.       admitted       to the       on             ,       where he/she was confined until             ,       . IV. Plaintiff was still undergoing extreme pain in the coccygeal area on or about             ,       and he/she went to see his/her family physician,       , in       , Mississippi.       immediately hospitalized       in the       in       , Mississippi where he/she was confined until             ,       . 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       for       ordered and medically necessary confinement from             ,       to             ,       . VI. Plaintiffs would show that the Defendant paid the claim to       ,       attending physician who ordered his/her hospital stay in the       but refused to pay said hospital claim in the amount of $       . Plaintiffs would further show that a pre - certification of       hospitalization was obtained from the Defendant. VII. Plaintiff       contacted the Defendant on several occasions concerning their non - payment of his/her hospital claim and was led to believe that the claim would be paid. Finally on             ,       ,       months after his/her hospital confinement to the       , Plaintiffs received a letter from the Defendant signed by       , legal counsel, stating that an outside consulting physician's opinion was that his/her hospitalization was not medically necessary. VIII. Plaintiffs would show that       was admitted to       upon the orders of       , a licensed physician in the State of Mississippi.       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       just and medically necessary hospital confinement claim to the       . Respectfully submitted,       and       BY: _________________________________________       OF COUNSEL: __________________________________________