LOS ANGELES -- The nation's largest health insurer, WellPoint, Inc., and its California subsidiary, Anthem Blue Cross, are being sued by a man who says he was denied a life saving liver transplant based on geography.
The lawsuit was filed by 61-year-old Ephram Nehme, a Lebanese immigrant, who claims he was automatically denied coverage for a liver transplant that his doctor said was medically necessary to save his life.
As a result of the insurer's decision, Nehme paid over $205,000 with his own money.
A civil trial got under way in the case Monday in Los Angeles County Superior Court.
Blue Cross lawyers have denied wrongdoing on the part of the company and say Nehme went outside of the coverage network to have his surgery in Indiana after the transplant was already approved at UCLA, leaving no obligation for any reimbursement for out-of-state care.
However, Nehme's lawyer Scott Glovsky argues that Blue Cross should pay the full cost of the transplant because the wait in California would have been fatal.
According to Glovsky, Nehme had a rapid progression of his liver disease in 2006 that originated with a tainted blood transfusion.
His nurses and doctors, including UCLA hepatologist Dr. Sammy Saab, recommended that he travel to Indiana University because they doubted he could get a transplant within a reasonable time at the Westwood medical center, Glovsky said.
"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."
The lawsuit comes at a time when Blue Cross is under fire for trying to increase its premiums up to 39 percent.
That move drew public outrage 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.
Patient Sues Blue Cross For Denying Liver Transplant
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