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Sunday, March 7, 2010

When you most need it: Anthem Blue Cross' denial for Ephram Nehme's liver transplant

Readers, I almost never use the name of providers and other organizations that are involved in outrageous decisions or errors. This case deserves to be an exception.

Anthem Blue Cross is a large insurer in California, part of the Wellpoint company. Anthem’s parent, Wellpoint, declared profits of $4.5 billion in the most recent quarter. A few weeks later, Anthem Blue Cross decided to raise its rates for members in California by 39%. A year earlier, Anthem's staff had denied an expensive life-saving liver transplant to Ephram Nehme.

Ephram had emigrated to the U.S. from Lebanon, moving to New York City after high school. There, he paid his way through accounting school by pumping gas and selling umbrellas. He yearned to start his own business. Twenty years after working for other people, he did so, opening a produce market in southern California, and then another one.

Following a blood transfusion in the 1970s, he had gotten hepatitis. He was able to manage the condition for many years with medication. But by late 2006, his doctor, a liver disease specialist at UCLA, told him it was time for a liver transplant.

Given the quirky rules for liver donation, the relatively small number of liver donors in California, and the urgency of his need, Ephram's doctors told him to promptly seek a transplant out of state. To Anthem Blue Cross, that meant "out of network," and they denied his request.

Ephram got a lawyer, who filed a lawsuit in Los Angeles Superior Court.

The denial stated that his score on a liver disease scale (the MELD – Model for End-Stage Liver Disease) was in a gray zone that did not necessarily justify a transplant. Ephram's lawsuit includes a copy of the letter from a doctor confirming that the MELD score was not in the gray zone, but rather was at a level indicating a prompt liver transplant was clearly required. In other words, the letter proved that Anthem had been incorrect. When learning of their error, staff at Anthem then changed their justification for the denial, saying that Ephram's "noncompliance," and inadequate medical therapy by the UCLA Transplant Center, had caused his situation, so that they need not pay for the very expensive procedure.

By 2006, Ephram was too sick to fight, so his wife called and begged Anthem to reconsider their denial. While the appeal was pending, Ephram's doctor convinced him that waiting too long could be disastrous. Anthem again formally refused to pay for the life-saving transplant.

Luckily, Ephram had enough money to move to Indiana and spent $200,000 of his savings for a hospital there, where he received a successful liver transplant in January 2007.

"If I hadn't," he said, "I'd be gone."

We don't give insurance companies many thousands of dollars a year of our money out of charity, or because we want to support their executives' lavish lifestyles. The only reason why people spend many thousands of dollars a year in health insurance is so that, if they become desperately ill, even a very expensive procedure will be paid for and provided. When an insurance company takes our premiums and realizes a huge profit, and jacks up their premiums so they will make even more in the future, and denies the life-saving procedures whose payment is the only thing that justifies their existence, something is deeply wrong with the status quo.

Advice: If you like our health insurance system to operate like this, do nothing to support healthcare reform, and it will act exactly like this when you most need it.

Read another story about an insurer’s denial for life-saving treatment. Thanks to Lisa Girion for writing the online Los Angeles Times story of October 7, which provided certain background details.

1 comment:

Anonymous said...

Anthem Blue Cross denied authorization for knee surgery for our son Nik following a college football injury. We appealed and lost. He is 21 years old now, 18 months later, depressed, disabled, and overweight, his knee untreated. Someone please help us!