Wednesday, October 14, 2009

Anthem sued over denial of transplant

Anthem sued over denial of transplant

California man, given OK by insurer there, says it wouldn't cover liver surgery in Indiana

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Ephram Nehme was gravely ill when Anthem Blue Cross of California agreed to pay for a liver transplant his physician said he needed to survive. Then, his condition went downhill fast.

Nehme's doctor told him he could die waiting for an organ in California and urged him to go to Indiana, where the waiting list was shorter. But Anthem Blue Cross, an affiliate of Indianapolis-based WellPoint, said no. It would not pay for a transplant in Indiana.

Nehme, a Lebanese immigrant with a rags-to-riches story, could afford to buy himself a new lease on life and did -- going to Indiana and paying $205,000 for a liver transplant there.

But he remains angry with Anthem and sued the company, accusing it of putting its bottom line ahead of his medical needs.

"I hope I can change it for other people," said Nehme, 61, who runs produce markets in Southern California's San Fernando and Simi valleys. "If somebody doesn't have a nickel in his pocket, what happens? He's dead."

"This is a tremendously important issue because most people aren't savvy enough about how to work this system, and it is totally stacked against them," said Bryan Liang, director of the Institute of Health Law Studies at California Western Law School in San Diego. "The insurers make sure they get the results they want. They hold all the cards."

Insurers say their pre-authorization reviews of big-ticket procedures, such as transplants, perform important services: ensuring patients get the care they need, when they need it, and keeping a lid on costs.

In Nehme's case, Anthem contends his policy made it clear that transplants were covered only at certain contracted hospitals, and that he was not sick enough to qualify for an exception.

Nehme begs to differ. When he needed a liver, the median wait time at the University of California-Los Angeles was more than two years. At the Clarian Transplant Center in Indianapolis, where he had his operation, it was about six weeks. Waiting for a liver at UCLA, Nehme believes, would have been a virtual death sentence.

"I shook my head and said I better do what I have to do now, and I'll fight (the insurance company) later," he recalled.

In the 1970s, Nehme contracted hepatitis from a blood transfusion. He managed the condition for years with medications. But by the fall of 2006, Nehme had run out of options. His longtime physician told him it was time for a transplant.

Joseph Tector, an Indiana University surgeon and medical director of the Clarian center in Indianapolis, testified that Nehme "was extremely unlikely to receive a liver transplant in sufficient time back in California at UCLA."

Nehme contends Anthem weighed none of this in denying the request.

Anthem physician-employees involved acknowledged in depositions they neither physically examined Nehme nor discussed his condition with his treating physicians at UCLA or Indiana University.

"They never saw me, and they are making a decision over the phone that it's not necessary for me to have the surgery," Nehme said.

Anthem defended its process, saying in a statement that its policy is to review all transplant requests "on a case by case basis by a medical expert"

Anthem declined to discuss Nehme's accusations. The case is set for trial this month in Los Angeles.

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