Consider the following actual case:*
Since 2004, a BCS insured agent, Deborah Jones, has assisted her client, our potential claimant–The Cholo Company, in procuring health insurance for its employees through the local BCBS plan. In 2007 and 2008, Deborah Jones submitted an Average Age Adjustment Appeal to the BCBS plan to help reduce The Cholo Company’s premium costs. The appeals were honored both of those years. Deborah Jones submitted the same type of appeal again in 2009 after speaking with The Cholo Company and the BCBS plan about her intent to do so before the end of May 2009. In the meantime, Deborah Jones went ahead and met with the employees of The Cholo Company to discuss approximate rates based upon the expected approval of the 2009 appeal. But on June 1, 2009, the BCBS plan denied the appeal claiming that The Cholo Company had a bad loss ratio for the last three years. As a result, the renewal rates Deborah Jones quoted to The Cholo Company’s employees were lower than the actual rates the BCBS plan charged for the renewal. This resulted in approximately $35,000 of additional premium cost to The Cholo Company. Deborah Jones contends that the BCBS plan representative admits never having check the loss ratio for The Cholo Company prior to the denial. The Cholo Company has retained counsel and is suing for $50,000.
*Actual names of individuals and companies have been changed and are fictitious.