CRITICAL CONDITIONS

WHEN MEGAN JONES ASKED HER INSURANCE COMPANY TO PAY FOR HER CANCER TREATMENT, SHE FOUND TRUTH WAS AT A PREMIUM.

As Megan Jones waited to be prepped for her double mastectomy, three people stood by her. On her left was Warren, her husband of ten years. On her right were her closest friends in America: Dianne and Gary Cushner.

They were all trying to comfort the 48-year-old Australian, who just days before had been shocked to learn she had invasive breast cancer. "You'll be fine, my love," Megan remembers her husband saying. Dianne just kept patting her right arm, murmuring that everything would be okay. But Gary Cushner held on to Megan's right hand all the way into the pre-op room--he was the very last to leave her side--and said one thing, and one thing only. "Don't worry, cutie pie," he told her, "you're covered. Now just concentrate on getting well."

Those words would drive the course of Megan Jones's life for months to come.
"If he hadn't said that, you see," Megan says, nervously pulling on the ends of the blond wig that unartfully hides the effects of chemotherapy, "I would've gone back to Australia. They have a different system for covering medicine and hospitalization. I would've been covered there for sure."

But because Gary Cushner, the man from whom she'd bought her health-insurance policy, assured his friend up until the last possible moment that she was covered, Megan went ahead with the surgery here. "They were telling her she didn't have much time to do it," Warren Jones says. "There wasn't a lot of time to lounge about."

"I had to know then if I was covered," Megan adds. "I kept asking Gary and asking Gary. I knew it was a serious diagnosis made shortly after the policy went into effect. I knew it might cause trouble, so I asked him directly. I said, `Gary, am I covered?' And he said, `Yes.'

Six months later, when Megan Jones sued friend and agent Gary Cushner, American Medical Security and United Wisconsin Life Insurance Company--the two corporations that underwrote and administered the insurance policy--no one disputed that Cushner had uttered those words. But despite the agent's assurances, AMS refused to cover Megan Jones's double mastectomy or any of the treatments that followed.

The company wouldn't pay, it said, because Megan Jones had a pre-existing condition.

Warren and Megan Jones came to Colorado four years ago. The Joneses had just sold their lucrative accounting business back in Canberra, Australia, and planned to use the proceeds to start up a coffee-bean business called Koala Bear. (They've since sold the franchise and taken accounting jobs.) They bought a small ranch house in Highlands Ranch and later, when Warren's "mum" prepared to move in with them, a larger house in the same development.

Megan Jones met Dianne Cushner in 1992, when the Joneses leased a car from Dianne's Englewood company. Dianne introduced the couple to her husband, an insurance agent, and the four quickly became friends, getting together for weekly dinner parties and movies, and even renting adjoining condominiums in Silvercreek that Thanksgiving so they could celebrate together.

Given how close the families became, it was only natural that the Joneses would consult Gary when they had questions about insurance. When the family first moved to this country, they'd applied for health insurance with a plan called Golden Rule. While the plan accepted Megan and her son, Christopher, it had declined coverage to Warren Jones because of a heart condition. In May 1994 the family switched to a Texas-based indemnity plan that would insure Warren, too. (Megan also kept her Golden Rule policy through June.)

But when Megan visited her regular physician, Linda Williams, on September 13, 1994, she was surprised to find that the Texas company didn't cover routine office visits. "I had just assumed the Texas plan was like Golden Rule," she says. "So I got back to the office and called Warren, and he said he'd call Gary."

Gary suggested Warren drop off a copy of the family's plan so that he could review it. "I brought it round the next day," Warren testified in court.

After that review, the Joneses say, not only did Cushner advise them that their plan was "no good," he recommended a better plan through AMS, a Wisconsin-based company. "He didn't tell us he was an agent for AMS," Megan says. "He just told us it was a good plan."

On September 16, 1994, Megan says, Gary Cushner called her at work and asked her to lunch so that she could sign the application. "I said to him, `But I haven't filled it out,'" she testified. "He said, `I filled it out.' I asked him how could he have filled it out, and he said, `I got the information from your application from Texas Life.' And I said, `You're very clever.'"

Under AMS, the monthly premium for all three members of the Jones family was $413. Gary Cushner arranged for the money to be automatically deducted from the Joneses' checking account.

The application was quickly accepted by AMS and its underwriter, United Wisconsin Life Insurance Company. The policy went into effect on October 1, 1994.

On October 20 Megan Jones was diagnosed with breast cancer.
No one was more shocked than she. After all, just eight months before, Megan had received what she thought were clinical assurances that she didn't have breast cancer. At the time, Megan had noticed "dimpling" on one of her breasts, and although she assumed it was due to some irregularity with her fourteen-year-old silicone implants, she expressed concern to Dr. Williams. The physician arranged for Megan to undergo a mammography and ultrasound testing. An April 11, 1994, letter to Jones contained the findings: "The results of your recent mammogram indicate no suspicion of breast cancer."

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