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California jury orders Anthem to pay for transplant performed "out of network"; appeal likely.

A California jury has ordered Anthem Blue Cross of California to cover the cost of a liver transplant a Los Angeles man opted to receive in Indiana after the insurance company informed him they would only cover the life-saving transplant if it was performed at a transplant center in its centers of excellence network. (Transplant News, October, 2009). The plaintiff, Ephram Nehme, initially wait-listed at the UCLA Medical Center, a hospital in Anthem's centers of excellence network. However, his physician told him he would likely die waiting for a liver because the center's waiting time for an organ was too long and recommended that he get on the waiting list in Indiana where the waiting time was considerably less. Nehme ultimately took his advice, listed at Clarian Transplant Center in Indianapolis, and was transplanted. Nehme was told the median waiting time at UCLA was more than two years, compared to about six weeks at Clarian.

Nehme, who paid for the $206,000 cost of the liver transplant out-of-pocket, then sued WellPoint, Inc., Anthem's Indianapolis-based parent company, for the cost plus damages. The case went to trial in Los Angeles on October 14th.

After five months of deliberations, the jury concluded Anthem Blue Cross should cover the cost of the out-of-state liver transplant and Nehme's legal expenses, which could dwarf the $206,000 cost of the transplant, the Los Angeles Times reported. The jury, which included at least three members with Blue Cross medical coverage, voted 10-2 that the company had breached its contract with Nehme and 9-3 that the health insurer acted in "bad faith" by refusing to pay for the out-of-state operation. After the 5 month trial, it only took the panel two days to reach a verdict.

"The message here is that you can't take people's money, promise to protect them, and then leave them to die in their time of need," said Nehme's lawyer, Scott Glovsky, according to the Times.

Glovsky said he will seek to broaden the jury's verdict under California's unfair competition law and ask the judge to order Blue Cross to allow its California customers to seek transplants at hospitals nationwide that do business with its parent WellPoint, Inc., the nation's largest insurer.

In a written statement, Blue Cross acknowledged the "jury's determination that Mr. Nehme's transplant should have been approved by Anthem Blue Cross despite the fact Mr. Nehem's Anthem Blue Cross contract states that transplants must be performed only ad California Centers of Excellence While we disagree with the jury's coverage determination, we are pleased that the jury did not award punitive damages and unanimously concluded that Anthem Blue Cross did not act with any malice toward Mr. Nehhme."

Blue Cross also stated that it had offered to settle the case out-of-court with Mr. Nehme several months ago for more money than the jury awarded and said in its statement "It is unfortunate that the time spent by the jury and the considerable costs of the trial could have been avoided."

However, prior to the start of the trial last October, Nehme told the Times "I hope I can change it for other people. I'm trying to save lives. There are a lot of people who need liver transplants, and they should be able to get them wherever they need them."
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Publication:Transplant News
Date:Mar 1, 2010
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