Internal Anthem Blue Cross/WellPoint Document: Only Patients Who 'Push Back' Get Covered Out of State Liver Transplants

LOS ANGELES, Feb. 25 /PRNewswire-USNewswire/ -- Evidence uncovered this week in the Los Angeles trial of Anthem Blue Cross, subsidiary of WellPoint Inc., which denied a grocer payment for an out-of-state liver transplant, shows the insurance giant will only approve exceptions to its in-state transplant network if patients "push back."

Consumer Watchdog, which posted the internal Anthem Blue Cross protocol at http://www.ConsumerWatchdog.org/resources/BlueCrossPushBack.pdf, said Blue Cross/WellPoint's policy shows the need for national health care reform that includes greater legal leverage for patients to make demands on their insurers and a public option to the private health insurance market.

Grocer Ephram Nehme paid $205,000 out of pocket for a liver transplant in Indiana that saved his life after Blue Cross said he wasn't sick enough to receive the transplant anywhere but at one of its California-contracted hospitals.

Nehme paid for his health insurance as an individual, so he is able to sue Blue Cross. 132 million Americans who receive health insurance through a private employer-paid policy cannot recover damages no matter what harm a denial causes due to a 1981 Supreme Court decision. Nehme also noted his Blue Cross policy premiums recently jumped 50% to $1,500 per month.

The judge in the case barred television cameras from the trial this week, despite many requests for permission.

"Congress needs to push back against Anthem Blue Cross's 'push back' policy," said Jamie Court, Consumer Watchdog president.  "Patients on their death beds shouldn't have to be the squeaky wheel to get the treatment that can save their life. Not only is Anthem raising premiums by 50% on patients like Mr. Nehme, this document shows Anthem is forcing critically ill patients to push hard for medical care that is supposed to be covered in their insurance policies. Congress needs to give patients more legal leverage to fight insurers with a strong national health reform package." 

According to the lawsuit, Blue Cross denied Californian Ephram Nehme's time-sensitive liver transplant at Indiana University hospital even though Nehme's doctor told him that the medically necessary liver transplant would probably not be available in time in California. The transplant was necessary to save Nehme's life.  

According to the lawsuit documents, Blue Cross denied the procedure without speaking with any of Nehme's doctors or reviewing all of Nehme's medical files. A Blue Cross transplant nurse recommended that Blue Cross cover the Indiana transplant before the insurance company denied the claim.

Nehme, who was able to pay for the transplant himself and save his own life, said as the trial began: "I paid insurance all my life. When I got really sick they said no. I am going to make them change their practice."

Read a recent Los Angeles Times story about Ehpram Nehme here: http://www.latimes.com/business/la-fi-transplant7-2009oct07,0,6616912.story

Download Consumer Watchdog's letter to Congress demanding new legal accountability of the health insurance industry here: http://www.ConsumerWatchdog.org/resources/PatientsBillofRightsHouseSenate.pdf 

Read about why 50 million Americans don't have the same rights as other patients to hold their health insurer accountable for denials of care here: http://www.consumerwatchdog.org/patients/EqualJusticeForPatients/

Consumer Watchdog is a nonpartisan consumer advocacy organization with offices in Washington, D.C. and Santa Monica, CA. Find us on the web at:http://www.ConsumerWatchdog.org

SOURCE Consumer Watchdog