Californian denied out-of-state liver transplant by Anthem Blue Cross to save money, lawyer says

Anthem Blue Cross refused to pay for one of its California members to get a liver transplant at an Indiana University hospital to save money, a lawyer for the patient told jurors Monday in a high-profile trial expected to shed light on how the insurance giant decides what medical care to cover--and what to deny.

"People buy insurance hoping they are never going to need it," lawyer Scott Glovsky told jurors in a downtown Los Angeles Superior Court. "And Blue Cross sells it hoping people will never need it. Why? Because they make more money."

In 2006, Blue Cross had approved a liver transplant for Ephram Nehme at the UCLA Medical Center. But, as Nehme's condition deteriorated, his UCLA physician told him he would die waiting for an available organ in California, and he recommended he go to a transplant center affiliated with Indiana University, where wait times are shorter.

Blue Cross refused to approve the surgery in Indiana. Nehme went to Indiana anyway, paying $205,000 out of pocket for the January 2007 surgery that saved his life. Now Nehme, 62, said he wants to change the way Blue Cross and other insurers do business.

"I'm trying to stop their unfair practices," Nehme said outside court. "I'm trying to save lives. There are a lot of people who need liver transplants, and they should be able to get them wherever they need them."

In a statement, Anthem Blue Cross said it has approved more than 98.5% of all transplant requests since July 2004 and considers each one on a case-by-case basis. The company says consulting physicians reviewed Nehme's case and determined that it was not necessary for him to go to Indiana to expedite his surgery.

Jerry Flanagan, healthcare director for the Consumer Watchdog advocacy organization, said at a news conference outside the courthouse that Nehme's case was "Exhibit A" in insurance industry abuses that healthcare reform efforts must address.

He said insurers raise insurance rates and deny treatment to boost profit. Nehme said he has received a notice that his Blue Cross premiums are set to increase March 1 by 50%--from $1,000 to $1,500 a month.

-- Lisa Girion

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Comments

[Steve]

Healthcare reform, anyone? Maybe this is just the "magic of the marketplace," which Sarah Palin says is working so well with healthcare. People need to look carefully at their insurance policies and not believe that there is some automatic right to any and all procedures that are necessary to maintain one's health. Right or wrong, there are big exclusions, including needing to have certain procedures done within an insurer's network. The premiums we pay, as high as they are, won't fund unlimited procedures for all insured. Unfair? Yup. Don't like it? Tell your Congressman. Right now the general feeling is to let things stay as they are.

[pmg]

I hope all those people working for mega-insurance corps. sleep well at night knowing that their decisions and rubber stamps on forms effectively KILL real people daily.

[IvanG]

Let's see. I buy insurance from a California insurer. It is priced based upon the insurer's contracts with medical providers in California. Instead, I want to be treated in New York, where treatment is twice as expensive. I think the insurer should pay what it would have paid for the same procedure here.

[My opinon means nothing]

The insurance companies are Sarah the quiter Palin's death panels.

[LIFESHARERS]

Your story about Ephram Nehme and Organ Donation highlighted the tragic shortage of human organs for transplant operations.

Over 50% of the people on the national transplant waiting list will die before they get a transplant. Most of these deaths are needless. Americans bury or cremate 20,000 transplantable organs every year.

There is a simple way to put a big dent in the organ shortage – give donated organs first to people who have agreed to donate their own organs when they die.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. People who aren't willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs.

Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers. LifeSharers is a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition. LifeSharers has over 13,500 members at this writing, including ¬¬1648 members in California.

Please contact me - Dave Undis, Executive Director of LifeSharers - if your readers would like to learn more about our innovative approach to increasing the number of organ donors. I can arrange interviews with some of our local members if you're interested. My email address is daveundis@lifesharers.org. My phone number is 615-351-8622.

[Jim]

While going to Indiana would have been cheaper, saying "NO" was the least costly, $80K salary paid for, easily. ($90K if the employee is really exceptional and let's a lot of expense drains fall off the record. (Die) )

[Debbie.Dunn]

On February 24 Congress listened to Wellpoint’s CEO Angela Braly explain why its necessary to raise rates for Anthem policy holders. When a company sends its claims processing to Manila, outsources its I.T. to India and targets long term U.S. employees for constructed termination, why does it need to raise rates? Before accepting these rate increases, Congress and the public should first look to how Wellpoint treats its own employees. Case # 06-CI-006392 Deborah Dunn vs Wellpoint Companies, Louisville, Kentucky.