ALJDEC decisions subject to certification as final
25C-149-INS · Department of Insurance and Financial Institutions - Insurance · 2026-02-19
IN THE OFFICE OF ADMINISTRATIVE HEARINGS
Mohammad Abbasian (Insured Member),
Petitioner,
V.
ManhattanLife Insurance and Annuity Company (Real Party in Interest),
Respondent.
No. 25C-149-INS
ADMINISTRATIVE LAW
JUDGE DECISION
HEARING: January 30, 2026.
APPEARANCES: Mohammad Abbasian appeared on his own behalf. Martha Boudreaux appeared for Respondent.
ADMINISTRATIVE LAW JUDGE: Samuel Fox
EXHIBITS ADMITTED INTO EVIDENCE: Dept. Exhibits parts 1 through 10.
_____________________________________________________________________
FINDINGS OF FACT
On or about November 20, 2025, the Arizona Department of Insurance and Financial Institutions (the Department) issued a Notice of Hearing for Mohammad Abbasian (Petitioner) setting the above-captioned matter for an administrative hearing. The Notice of Hearing stated:
On or about November 1, 2025, Mohammad Abbasian . . . filed a Notice of Appeal pursuant to Arizona Revised Statutes [(A.R.S.)] §§20-2537(H) and 41-1092 et seq., to appeal the [Department’s] Director [(Director)] determination that, pursuant to ARS §20-2537(F), the services Petitioner seeks are not covered benefits under the terms of ManhattanLife Insurance and Annuity Company [(Respondent)].
As early as 2018, Petitioner had coronary atherosclerosis and essential hypertension. Petitioner had suffered from chronic coronary artery disease: he had symptoms and was taking medication to manage it.
Petitioner’s Hospital Confinement and Other Fixed Indemnity Insurance Policy (the Policy) became effective on March 1, 2024. The Policy stated in all capital letters: “THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE.” The Policy limited coverage for Pre-Existing Conditions: “[w]e will not pay benefits for events that result from or are related to a Pre-Existing Condition, or its complications, until the Covered Person has been continuously insured under this policy for 12 months.” It defined Pre-Existing Conditions as follows:
A condition and related complications:
1. for which medical advice, diagnosis, care, or treatment was sought, received or recommended from a provider or for which Prescription Drugs were prescribed during the 12-month period immediately prior to the Covered Person’s Effective Date, regardless of whether the condition was diagnosed, misdiagnosed, or not diagnosed; or,
2. that produced symptoms during the 12-month period immediately prior to the Covered Person’s Effective Date which reasonably should have caused or would have caused an ordinarily prudent person to seek diagnosis or treatment.
On or about June 21, 2024, Petitioner was treated for a cardiac event at the Chandler Regional Medical Center. At the hospital, Petitioner self-reported that he had been experiencing intermittent chest pain and shortness of breath for the past six months. A claim was submitted to Respondent for the treatment.
On July 23, 2024, Respondent sought additional information about Petitioner’s treatment from the prior 12 months.
On or about February 4 and 5, 2025, Respondent issued an Explanation of Benefits, explaining that the claim was denied because it was a pre-existing condition under the Policy and not covered.
On or about February 26, 2025, Petitioner appealed the denial on the basis that it was an emergency procedure, it violated the coverage requirements, and it was a failure to act in good faith.
On or about February 26, 2025, Respondent confirmed its denial, stating that the Policy was a Hospital Confinement and Other Fixed Indemnity Insurance Policy, not a major medical insurance policy. It also stated that six months prior to the hospitalization, Petitioner had signs of coronary artery disease.
On or about April 17, 2025, Petitioner appealed again, stating the procedure was medically necessary, his cardiologist could support the necessity, and the Policy should have covered the procedure.
On or about April 22, 2025, Respondent confirmed the denial, affirming the prior denial for the same reasons.
On or about April 30, 2025, Petitioner sought third-party review from the Department, arguing that there was no pre-existing condition.
On October 15, 2025, the Department issued its Notice of Determination, denying Petitioner’s claims.
Petitioner timely appealed, and the matter was referred to the Arizona Office of Administrative Hearings.
Ms. Boudreaux testified in support of Respondent’s determination and the Department’s determination.
Petitioner testified that chronic coronary artery disease was different from acute coronary artery disease, and the chronic coronary artery disease symptoms and treatment were different from acute coronary artery disease symptoms and treatment. Petitioner testified that he had risk factors for coronary artery disease, specifically high blood pressure and medication that he was taking. He testified that 90% of men his age have the same condition. Petitioner testified that chronic coronary artery disease can progress to acute coronary artery disease, but lifestyle, food, and treatment can prevent that progression. Petitioner believed that the salesperson for the Policy misled him.
Petitioner believed that Respondent took the risk of his heart disease progressing when it entered the agreement.
Respondent believed that Petitioner took the risk of his heart disease progressing when he entered the agreement.
CONCLUSIONS OF LAW
This matter is within the jurisdiction of the Director of the Arizona Department of Insurance and Financial Institutions.
Petitioner bears the burden of proof and the standard of proof on all issues in this matter is that of a preponderance of the evidence. A preponderance of the evidence means “proof which leads the [trier of fact] to find that the existence of the contested fact is more probable than its nonexistence.”
The Policy was clear that it was supplemental insurance, not a primary health insurance. The Policy was clear that it did not cover pre-existing conditions under defined circumstances; relevantly, when the insured had symptoms or treatment within twelve months before the effective date of the Policy.
Petitioner testified that he had symptoms of coronary artery disease and was receiving treatment for coronary artery disease. Petitioner testified that chronic coronary artery disease can progress into acute coronary artery disease.
Under the Policy, chronic coronary artery disease symptoms and treatment fall within the definition of a pre-existing condition, and many heart-related medical events, including Petitioner’s, would be excluded based on shared symptoms and treatment or as a complication of the chronic coronary artery disease. Petitioner’s argument that acute coronary artery disease is distinct from chronic coronary artery disease is medically correct; however, both share symptoms (chest pain), risk factors (lesions), preventative treatment (cholesterol medication), etc., making the distinction between chronic and acute coronary artery disease irrelevant under the Policy.
Petitioner’s frustration with the salesperson’s representations and whether the salesperson mislead Petitioner cannot be addressed here.
Petitioner’s argument that Respondent accepted the risk of Petitioner having a heart-related medical event fails. The Policy is clear that such events would not be covered for the first year, meaning Petitioner accepted the risk of no coverage for such events for the first year.
ORDER
It is recommended the Director of the Department should deny Petitioner’s appeal.
In the event of certification of the Administrative Law Judge Decision by the Director of the Office of Administrative Hearings, the effective date of the Order will be forty (40) days from the date of that certification.
Done this day, February 19, 2026.
/s/ Samuel Fox
Administrative Law Judge
Transmitted by either mail, e-mail, or facsimile to:
Charles Bassett, Interim Director
Department of Insurance and Financial Institutions - Insurance
Mohammad Abbasian
[email redacted]
ManhattanLife Insurance and Annuity Company
[email redacted]
By: OAH Staff