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.
The news from his doctor was bad. The word from his insurer was worse.
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 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 the San Fernando Valley and Simi Valley. "If somebody doesn't have a nickel in his pocket, what happens? He's dead."
The case offers a rare glimpse into the life-and-death decisions insurers make behind closed doors and illustrates one of the most emotional questions in healthcare: Who should decide what is best for a patient -- doctors or insurers?
"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, play important roles: ensuring that patients get the care they need, when they need it, and keeping a lid on costs.
In Nehme's case, Anthem says it did nothing wrong. It contends that 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.
"Mr. Nehme was placed on a waiting list by his treating physicians for organ donation at UCLA but sought approval for transplant services at a different facility that was not within our transplant network," WellPoint Inc., Anthem's Indianapolis-based parent company, said in a statement.
"Upon additional third party review," the company said, "it was determined that Mr. Nehme's condition did not present medical urgency to require an emergency [out-of-network] transplant."
Nehme begs to differ. When he needed a liver, the median wait time at UCLA 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.
Born in Beirut on Christmas Day 1947, Nehme grew up in a two-bedroom house with seven sisters, two brothers, a grandmother and his parents. He moved to New York City after high school, paying his way through accounting school by pumping gas and selling umbrellas on rainy days.
He worked for several companies but yearned to be his own boss. He also missed the markets in Beirut where he remembered his mother jostling with other women for the best piece of fruit.
So, in 1992, after working for others for 20 years, Nehme and his wife, a pharmacist, scraped together $90,000 in savings and opened Valley Produce Market, now located on Vanowen Street in Reseda. He opened a second market four years ago in Simi Valley. He employs more than 170 people.
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, Sammy Saab, a board-certified liver disease specialist at UCLA, told him it was time for a transplant.
In an effort to ensure that organs go to the right patients, U.S. transplant centers rank patients waiting for livers on a scale, and the harvesting region gets first dibs, according to United Network for Organ Sharing guidelines.
Both sets of rules worked against Nehme. For starters, his condition included problems that aren't factored into the ranking system. To make matters worse, California has a higher ratio of patients to organs than other parts of the country. As a result, in California waits are longer and more people die waiting than in other parts of the country.
There are no rules against relocating for transplants, and patients often do. Notably, Apple Inc. co-founder Steve Jobs traveled to Tennessee this year for a liver 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 that Anthem considered none of this.
His lawsuit accuses the insurer of reflexively denying his request for an Indiana transplant, then rubber-stamping that decision in a series of hasty and inadequate reviews conducted by physician-employees without training in transplant specialties.
A nurse in Anthem's transplant department who reviewed the request made an internal recommendation that Anthem authorize it, court documents show.
"Due to the increased wait time in California, and the rapid progression of his disease I am recommending for this member approval for going oon [out of network] for his liver transplant," wrote Pamela Adelman, the nurse.
The next day, however, Anthem denied the request.
Anthem physician-employees involved in the decision acknowledged in depositions that they neither physically examined Nehme nor discussed his condition with his treating physicians at UCLA or Indiana University.
One of the employees, a family practitioner by training, testified that she reviewed 25 to 40 treatment denial appeals a day for Anthem.
"They went out of their way to find a way to not pay for the transplant," said Nehme's lawyer, Scott Glovsky.
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. If determined that a transplant is required on an immediate, emergency basis, Anthem care managers assist members in finding the most appropriate [network] facility for treatment. If no in-network facility is identified to provide these necessary services, out of network transplants are approved and coordinated."
The company declined to discuss Nehme's accusations in detail. The case is set for trial Oct. 14 in Los Angeles.
In 2006, Nehme was too sick to fight, so his wife called and begged Anthem to reconsider. While the appeal was pending, Nehme's doctor convinced him that waiting too long could be disastrous.
"I waited and waited and waited," Nehme recalled, "until Dr. Saab said, 'How are your finances? What are you waiting for?' "
Then Anthem called his wife to say it was upholding its earlier decision.
"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.
He moved to Indianapolis and wired more than $200,000 from his bank to the hospital there.
Two months later, on Jan. 13, 2007, Nehme underwent a successful liver transplant.
"If I hadn't," he said, "I'd be gone."
Unlike Ephram Nehme, most people are unable to sue for damages when their health insurer turns down a request for treatment.