National Health Care Reformers Should Pay Attention to Lawsuit Alleging That Nation's Largest Insurer Denies Liver Transplants Automatically
Los Angeles, CA -- A trial beginning today targeting the nation’s largest health insurer, WellPoint Inc., and its California subsidiary, Anthem Blue Cross, illustrates how difficult, and how necessary, President Obama’s call to curb insurance company abuses will be, said Consumer Watchdog. The Los Angeles trial alleges that Blue Cross has automatically denied requests for out-of-network liver transplants, no matter what a doctor says is necessary, often without even reviewing all patient records. The trial will shed light on the delay and denial of life-saving treatment in cases that might cut into insurance company profits, the consumer advocacy group said.
Consumer Watchdog urged President Obama, White House representatives, and the national news media to follow the trial.
Click here to download the lawsuit filed in Los Angeles Superior Court.
"Denials of life-saving, medically necessary care, is the MO of an industry that puts profits before patients and yet another example of why Americans need a public option to the private insurance market,” said Jerry Flanagan, Health Care Policy Director for Consumer Watchdog. “When the nation’s largest PPO is alleged to have automatically denied liver transplants at out-of-network hospitals it is clear that Congress must require more transparency when insurance company bureaucrats override a doctor’s prescription, and greater legal accountability when they deny access systematically.”
President Obama’s outline of White House health reform proposals, released today, calls for “a stronger appeals process” when insurers deny care, but insurers are expert at using the technicalities of such appeals to delay care until the treatment is no longer viable or even until the patient dies, said Consumer Watchdog. Patients’ rights to hold insurance companies accountable in court must be strengthened and equalized, no matter how patients obtain their insurance, said the group. Oversight of insurance company practices must be strengthened as well, ideally in concert with a public alternative to for-profit insurance.
According to the lawsuit, Blue Cross denied Californian Ephram Nehme’s time-sensitive liver transplant at Indiana University hospital even though Nehme’s doctor told him that the medically necessary liver transplant would probably not be available in time in California. The transplant was necessary to save Nehme’s life. As a result of Blue Cross’s denial, Nehme paid more than $205,000 out of pocket for the surgery.
According to the lawsuit documents, Blue Cross denied the procedure without speaking with any of Nehme’s doctors or reviewing all of Nehme’s medical files. A Blue Cross transplant nurse recommended that Blue Cross cover the Indiana transplant before the insurance company denied the claim.
Nehme, who was able to pay for the transplant himself and save his own life, said as the trial began: “I paid insurance all my life. When I got really sick they said no. … I am going to make them change their practice.”
Leading health care legislation pending in Congress would require all Americans to have health insurance, but does not provide additional legal accountability for the industry or limit what insurance companies can charge for coverage.
Click here to read a recent LA Times story about Ehpram Nehme.
Click here to download Consumer Watchdog's letter to Congress demanding new legal accountability of the health insurance industry.
Click here to read about why 50 million Americans don’t have the same rights as other patients to hold their health insurer accountable for denials of care.
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Consumer Watchdog is a nonprofit, nonpartisan consumer advocacy organization with offices in Washington, D.C. and Santa Monica, CA. Find us online at: www.ConsumerWatchdog.org