Anthem Blue Cross denied California man transplant coverage

Legal news for California insurance litigation attorneys. Blue Cross refused to pay for out-of-sate transplant, lawsuit soon followed.

A lawsuit was filed after Anthem Blue Cross denied a liver transplant at an Indianapolis hospital.

Los Angeles, CA—Anthem Blue Cross has been ordered by a Los Angeles jury to cover the costs of a liver transplant that the insurance company pulled out of because the patient received the surgery out-of-state. Blue Cross was also ordered to pay the plaintiff’s legal expenses, which could exceed the $206,000 cost of the transplant, as reported by the Los Angeles Times.

In 2006, the plaintiff’s, Ephram Nehme, 62, liver began to fail, and he was subsequently placed on the UCLA’s transplant list. Blue Cross approved the procedure, because UCLA was apart of its contracted network of hospitals. As Nehme’s health steadily deteriorated, the UCLA physician recommended that he be put on the transplant list at Clarian Transplant Center in Indianapolis; the wait was a mere 6 weeks at Clarian, compared to UCLA’s median wait time of two years. Blue Cross denied Nehme coverage because he had the procedure done at the unaffiliated Indianapolis hospital, which caused him to pay out-of-pocket for his transplant in January 2007.

The lawsuit asserts that Blue Cross denied him coverage for the Indiana transplant to save the insurance company money. The jury, which consisted of three Blue Cross medical coverage holders, decided on a 10 to 2 vote that the insurance company broke its contract with the plaintiff, after a two-day deliberation. A 9 to 3 vote contended that Blue Cross acted in “bad faith by refusing to pay for the out-of-state operation.” Lawyers representing Nehme are seeking to broaden the jury’s ruling to be covered under California’s unfair competition law. Nehme’s attorneys will be asking the court to order the insurance giant to “allow California members to pursue organ transplants at hospitals nationwide that do business with its parent, Indianapolis-based WellPoint Inc., the nation’s largest health insurer.”

Blue Cross stated they offered to settle with Nehme out-of-court, for a larger sum of money that was awarded, but he denied. Nehme contends that the case is “not about the money,” instead he saw the lawsuit as an avenue to “pressure Blue Cross to stop denying out-of-state transplants.”

Legal News Reporter: Nicole Howley-Legal news for insurance litigation lawyers in California.

About the Author Nicole