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.

The Senate's Christmas gift for families like the Mains: Pre-existing conditions

The Yes from Senator Ben Nelson is the crucial 60th vote in favor of the health reform bill. That's a major milestone toward the bill's passage.

On this morning's Meet the Press TV show, Sen. Nelson said that the early benefits of the bill, if it passes, will prevent insurance companies from denying coverage to children for their pre-existing conditions.

Who'll benefit? Hesper Main offers her example:
I too am a victim of Mega Life. Months before my son was diagnosed with leukemia we decided that we had let the children go without insurance for too long. I found an inexpensive insurance for the self-employed and called. The woman who set up our policy was a quick speaking, spastic, all over the place mess. She explained to us how wonderful a hospital-based plan was and my husband and I were not well educated in health insurance to doubt what she was saying. Now, the bills are so high that we are going to have to file bankruptcy. The woman at Mega Life completely misrepresented her company and duped us into purchasing our policy. My son is healthy and in remission, even though we are struggling with getting these bills paid. The doctors and hospital have never denied my son care. Thank God! I shudder to think of how many people out there are going through the same thing that we are.

Read another story about an insurer’s denial of a pre-existing condition. Thanks to the bloggers at Health Care for All for posting her comment, reprinted here.

Outside the chemo treatment room: Insurance denials

From Nicholas Kristof's column:

I regularly receive heartbreaking emails from readers simultaneously combating the predation of disease and insurers. One correspondent, Linda, told me how she had been diagnosed earlier this year with abdominal and bladder cancer – leading to battles with her insurance company.

"I will never forget standing outside the chemo treatment room knowing that the medication needed to save my life was only a few feet away, but that because I had private insurance it wasn't available to me," Linda wrote. "I read a comment from someone saying that they didn't want a faceless government bureaucrat deciding if they would or would not get treatment. Well, a faceless bureaucrat from my private insurance made the decision that I wouldn't get treatment and that I wasn't worth saving."

Advice: Insist that your representatives in Congress vote for a public plan that will cover people like Linda.

Read another story on an insurer’s denial of chemotherapy treatment.

Thanks to Nicholas Kristof for the source column in today's New York Times.

Managing the risk: Blue Cross Blue Shield of Texas' rescission of a breast cancer patient's coverage

Robin Beaton worked as a nurse for 30 years, and had retired by age 59. She had insurance coverage in an individual policy through Blue Cross Blue Shield of Texas. Though she had had acne, and a rapid heartbeat, she didn't mention them on her insurance application. However, Blue Cross accepted her application, and she paid premiums regularly. Then, when she was diagnosed with an aggressive form of breast cancer, her doctor told her she needed a double mastectomy. At that time, Blue Cross retroactively canceled ("rescinded") her policy, as she recently testified to the US Congress.

The insurance company said the fact that she had seen a dermatologist for acne, who mistakenly entered a notation on her chart that suggested her simple acne was a precancerous condition, allowed Blue Cross to leave her in the lurch.

Such a practice by insurers, of reviewing the person's health questionnaire, and rescinding policies, upon learning of an expensive condition like cancer, is quite common, said the three insurance CEOs who testified. The congressional panel reported that three insurers had done this almost 20,000 times in a five-year period.


I spoke with a senior spokesperson for Blue Cross Blue Shield of Texas, and asked these questions:

1. What are the steps of the review process routinely used by BCBS of Texas to consider whether current insureds have pre-existing conditions that would affect their eligibility for covered services?

2. Which diagnoses and conditions of an insured do NOT trigger an electronic review of pre-existing conditions?

3. Which diagnoses and conditions of an insured do NOT trigger a review of pre-existing conditions that uses phone calls, manual chart review, or other ways of collecting information?

4. Were BCBSTX employees rewarded financially based on the rescissions they identify?

5. Will your CEO commit to limiting rescissions to only policyholders who intentionally lie or commit fraud to obtain coverage? If not, why not?

This was the formal answer by the BCBS of Texas spokesperson:
"If an applicant for individual health insurance does not disclose noteworthy medical conditions during the application process, coverage may have been offered that cannot be properly supported by the premiums received for that individual's coverage. During our review of such cases, every effort is taken to retain the member's coverage, while still appropriately managing the risk and maintaining affordable rates for all individuals covered by such plans. In fact, Blue Cross and Blue Shield of Texas often allows members to retain their coverage by applying an increased premium rate, adding a specific coverage exclusion rider or removing the individual's coverage rather than the entire family's coverage. As such, a very small percentage of individual members actually lose coverage when compared to the 300,000 members covered by individual plans in Texas.

It is also worth noting that BCBSTX supports health care reform that guarantees insurance for any individual who applies for it regardless of health status as long as all individuals participate in a health insurance pool."

Advice: Share this story, and support a public insurance option as an alternative to private insurance.

Read another story about insurers’ rescissions.

Thanks to Paul Begala for the source article in CNN.com on June 19.

Just before his stem cell transplant: Insurers' recission of coverage

Peggy Raddatz, an Illinois resident, testified before a subcommiteee of the U.S. House of Representatives yesterday that Fortis Insurance Company attempted to drop her brother Otto from coverage just before he was to receive a stem cell transplant to treat his lymphoma. According to Peggy, the company sought to cancel her brother's insurance because it said he had failed to disclose that he had previously suffered gallstones and an aneurysm when he first signed up for his insurance policy.

But, Peggy said, her brother had never been informed of those conditions. They showed up only in a CT scan that was never revealed to him, she said.

Eventually, the company relented after they received weeks of her phonecalls, and pressure to do so from the Illinois Attorney General's office. Peggy said most policyholders who lose their insurance are not as lucky. Indeed, insurers have culled many thousands of such beneficiaries from their rolls.

You can see the brief video of her testimony here.

Do you want the option to choose coverage through the government instead of an insurer's coverage?

Advice: Call your Congressman and insist that the coming health care law include a public insurance option.

Read a story on why President Obama feels so strongly about insurance company denials. Thanks to Patrick Yoest for the source story today in CNN Money.com.

While she lay in bed: Insurance denials for pre-existing conditions

"My mother died very suddenly and very young," her adult son told AARP Bulletin last fall.

Ann Dunham died in 1995 at age 52 after working as a consultant for the U.S. Agency for International Development, the Ford Foundation and Women's World Banking. She taught her son an important lesson about access to health care. "She'd go from contract to contract and would be able to buy health insurance [only] when she got a new contract," her son said. "When she got sick, she had just signed up for a new job, a new contract, and she had a lot of arguments of whether this was a pre-existing condition of which she had no knowledge whatsoever….As someone who watched my mother argue with insurance companies while she lay in bed dying of cancer, I will make sure those companies stop discriminating against those who are sick and who need care the most."

This is more than wishful thinking on the son's part, as he is now president of the United States – Barack Obama. As he said frequently during the presidential campaign, "These are not abstractions for me."

Advice: Fight for health insurance for all.

Read a story about a pre-existing condition.

Thanks to Jim Toedtman for the source article in the March issue of the AARP Bulletin.

They declined to pay for chemotherapy: Overturning an insurer's denial

David Foglesong, a history professor from Montgomery Township, N.J., began searching medical databases soon after Horizon Blue Cross Blue Shield of New Jersey declined to pay for a targeted chemotherapy treatment for his wife, RoseMary. During one library visit, he found a new study that showed the treatment had helped patients with conditions similar to his wife's disease, advanced sarcoma that had spread to her liver.

The couple, advised by Patient Advocate Foundation, a nonprofit group, solicited new letters from RoseMary's doctors, and her primary oncologist argued on her behalf in a conference call with the insurance company's reviewers in June. The company reversed its earlier decision, and RoseMary, 49, got the treatment in July.

Horizon officials say the procedure was initially denied because it was deemed experimental and not the standard for Ms. Foglesong's condition. The company said a review committee reversed that decision because of the "whole totality of her case," including the medical literature.

Advice for denied insurance beneficiaries: Look into it like David did, and consider filing an appeal with your insurer.

Read another insurer denial story.

Thanks to Anna Wilde Mathews for the source story in the Wall St. Journal's Personal Finance section today.