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Jury Rules Blue Cross Must Pay for Out-of-State Transplant

Source: Los Angeles Times

Posted on 16 Mar 2010

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In a decision that could have far-ranging implications for the insurer, Anthem Blue Cross should refund the $206,000 a California-based client paid for an out-of-state liver transplant when the insurer refused to cover him, a Los Angeles jury has concluded.

The plaintiff’s attorney is asking the judge to broaden the verdict under California’s unfair competition law and order Blue Cross to allow its 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.

In addition, the jury ordered Blue Cross to pay the insured’s legal expenses, which could be far more than the cost of the transplant.

Blue Cross approved Ephram Nehme's liver transplant in late 2006, and he was on the waiting list at UCLA Medical Center. But the company refused to pay when Nehme, gravely ill and fearing for his life, decided to have the operation in Indiana, where wait times are far shorter than in California.

The jury, which included at least three members with Blue Cross medical coverage, voted 10 to 2 that the company breached its contract with Nehme. It voted 9 to 3 that the health insurer acted in bad faith by refusing to pay for the out-of-state operation. The panel deliberated for less than two days.

"The message here is that you can't take people's money, promise to protect them, and then leave them to die in their time of need," said Nehme's lawyer, Scott Glovsky.

In a statement, Blue Cross acknowledged "the jury's determination that Nehme's transplant should have been approved by Anthem Blue Cross despite the fact that Nehme's Anthem Blue Cross contract states that transplants must be performed only at California Centers of Excellence.

"While we disagree with the jury's coverage determination, we are pleased that the jury did not award punitive damages and unanimously concluded that Anthem Blue Cross did not act with any malice toward Mr. Nehme," the company said. A spokeswoman said the company had not decided whether it would appeal.

Blue Cross also said it offered to settle the case with Nehme several months ago for more money than the jury awarded.

"It is unfortunate that the time spent by the jury and the considerable costs of this trial could have been avoided," the company said.

Nehme, a 62-year-old produce merchant and grandfather, said the case was not about money. Before the trial began he pledged to donate any winnings to liver research.

The verdict comes amid growing outrage over premium increases imposed by Blue Cross and other insurers. Nehme's premium, for example, increased 50% March 1 to $1,500 a month.