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

February 22, 2010 |  1:56 pm

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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