Opinion
NO. 2018 CW 0871
09-04-2018
DR. JAMES J. LANASA, JR. v. VANTAGE HEALTH PLAN, INC.
In Re: Vantage Health Plan, Inc., applying for supervisory writs, 19th Judicial District Court, Parish of East Baton Rouge, Nos. 619,025 & 659,174. BEFORE: GUIDRY, THERIOT, AND PENZATO, JJ.
WRIT GRANTED. The November 6, 2017 judgment of the 19th Judicial District Court affirming the April 18, 2017 judgment of the Baton Rouge City Court is hereby reversed and judgment is rendered herein in favor of relator, Vantage Health Plan, Inc., dismissing the claims filed against it by respondent, Dr. James J. LaNasa, Jr. We find no ambiguity in the Vantage Certificate of Coverage when construed as a whole. See La. C.C. art. 2050; Sims v. Mulhearn Funeral Home, Inc., 2007-0054 (La. 5/22/07), 956 So.2d 583, 589. We conclude Vantage properly denied payment of Dr. LaNasa's claims as no pre-authorization for the out-patient surgery was obtained as required by the contract. We further find that, even had the surgery been authorized, the insured would have been responsible for the entirety of Dr. LaNasa's charges since she used the services of an out-of-network provider, she had not met her deductible, and the amount owed to Dr. LaNasa was below the amount of her deductible.
JMG
MRT
AHP
COURT OF APPEAL, FIRST CIRCUIT /s/_________
DEPUTY CLERK OF COURT
FOR THE COURT