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Seventh Circuit upholds ruling in class action over dental services cap

By Jessica M. Karmasek | Sep 28, 2012


INDIANAPOLIS (Legal Newsline) - A federal appeals court ruled this week that Indiana cannot violate state and federal Medicaid laws, and people without means in the state must receive "medically necessary" dental treatment.

In its ruling Wednesday, the U.S. Court of Appeals for the Seventh Circuit sided with plaintiff Sandra Bontrager and others like her in a class action filed against the Indiana Family and Social Services Administration, or FSSA.

In 2009, Bontrager's doctors ordered implant treatments -- including two endosteal implants and two implant abutments for her lower jaw.

When she sought payment of these services through Medicaid, her claim, although covered and medically necessary, was denied to the extent her requested treatment exceeded Indiana's $1,000 annual limit on such services.

Bontrager was unable to pay for the services on her own.

She subsequently filed a class action complaint in Elkhart County Superior Court in May 2011.

Bontrager's lawsuit alleges that the FSSA, which administers the state's Medicaid program, violated state and federal Medicaid laws by instituting the $1,000 annual cap on dental services, even when such services are covered and medically necessary.

Her attorney, Jacquelyn Bowie Suess for the American Civil Liberties Union of Indiana, said even though the agency had denied Bontrager's claim, saying the requested services were not "covered dental services," it was clear the treatments her doctors ordered were both medically necessary and covered under the program.

"The $1,000 cap is often the only reason people without means don't receive dental treatment ordered by their doctors -- care that can well exceed that small subsidy," Suess said in a statement Wednesday.

In a ruling last year, the U.S. District Court for the Northern District of Indiana granted Bontrager's request for a preliminary injunction.

The court held that Indiana is required to cover all medically necessary dental services, irrespective of the monetary cap.

The Seventh Circuit affirmed.

The court said it agreed with the district court that the cap prevents the state from providing coverage for all medically necessary services, and partial payment for such services does not constitute "some coverage."

"The State's monetary contribution has no effect (i.e., the State ends up paying nothing) and the Medicaid recipient is left without recourse," Judge Michael Stephen Kanne wrote in the court's 16-page opinion.

"And if the indigent individual has already used a portion of her $1,000 allotment toward other dental services, she would be required to come up with even more money to pay for the procedure."

Suess said the ACLU was "thrilled" with the Seventh Circuit's ruling, adding that proper health care "makes an enormous impact on quality of life."

Jane Henegar, executive director of ACLU of Indiana, added, "The civil liberties guaranteed to each one of us prevents government from unfairly and arbitrarily limiting services.

"The role of the ACLU of Indiana in this case is to ensure that the State doesn't shirk its responsibilities under state and federal law by denying health care treatments it has already said it would provide."

From Legal Newsline: Reach Jessica Karmasek by email at jessica@legalnewsline.com.

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