Ephram Nehme wanted to visit a doctor. Turns out he also needed to hire a lawyer.
His trial begins today in a Los Angeles courtroom, where Nehme is alleging that the nation's largest health insurer, WellPoint Inc., and its California subsidiary, Anthem Blue Cross, automatically denied coverage for a liver transplant that his doctor said was medically necessary.
According to a statement issued on Nehme's behalf, Anthem never spoke to any of the doctors nor reviewed all of the medical files related to the case. It also states that a Blue Cross transplant nurse recommended the procedure before the claim was denied. As a result of the insurer's decision, Nehme paid over $205,000 out-of-pocket. "The transplant was necessary to save his life," says the release from Consumer Watchdog.
The case hinges not only on when Nehme needed the surgery, but where he got it. According to a report the Los Angeles Times ran in October, "Nehme's doctor told him he could die waiting for an organ in California and urged him to go to Indiana, where the waiting list was shorter. But Anthem Blue Cross said no. It would not pay for a transplant in Indiana."
In the court of public opinion, the timing of the lawsuit couldn't be much worse for the defendant. As the state's largest for-profit insurer, WellPoint's Anthem Blue Cross unit came under fire earlier this month for proposing premium increases of up to 39 percent. The announcement drew public ire in California, as well as attention in Washington. Health and Human Services Secretary Kathleen Sebelius demanded "a detailed justification," and President Barack Obama mentioned the large increase while stumping for health care reform.
Anthem quickly decided to push back the rate hike from March 1 to May 1. The company was back in the headlines just days later, when three of WellPoint's directors cashed in stock options worth a combined $625,517.
Even if they aren't winning any popularity contests, Anthem hopes to win the Nehme case on legal grounds. The company told the LA Times that they did nothing wrong:
"Mr. Nehme was placed on a waiting list by his treating physicians for organ donation at UCLA but sought approval for transplant services at a different facility that was not within our transplant network," WellPoint Inc., Anthem's Indianapolis-based parent company, said in a statement.
"Upon additional third party review," the company said, "it was determined that Mr. Nehme's condition did not present medical urgency to require an emergency [out-of-network] transplant."
A full copy of the lawsuit is available from Consumer Watchdog in PDF format.