Anthem Blue Cross should reimburse California man for transplant, jury says


A Los Angeles jury concluded Monday that Anthem Blue Cross should cover the cost of an out-of-state liver transplant that a California man paid for after the insurer balked.

In addition, the jury ordered Blue Cross to pay plaintiff Ephram Nehme’s legal expenses, which could dwarf the $206,000 cost of the transplant.

Blue Cross approved Nehme’s liver transplant in late 2006, and he was on the waiting list at UCLA Medical Center. But the company refused to pay when Nehme, gravely ill and fearing for his life, decided to have the operation in Indiana, where wait times are far shorter than in California.

The jury, which included at least three members with Blue Cross medical coverage, voted 10 to 2 that the company breached its contract with Nehme. It voted 9 to 3 that the health insurer acted in bad faith by refusing to pay for the out-of-state operation. The panel deliberated for less than two days.

“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.

At a hearing set for next week, Glovsky said he would seek to broaden the jury’s verdict under the state’s unfair competition law. He will ask Superior Court Judge Kenneth Freeman to order Blue Cross to allow its California members to pursue organ transplants at hospitals nationwide that do business with its parent, Indianapolis-based WellPoint Inc., the nation’s largest health insurer.

In a statement, Blue Cross acknowledged “the jury’s determination that Mr. Nehme’s transplant should have been approved by Anthem Blue Cross despite the fact that Mr. Nehme’s Anthem Blue Cross contract states that transplants must be performed only at 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. Nehme,” the company said.

A spokeswoman said the company had not decided whether it would appeal.

Blue Cross also said it offered to settle the case with Nehme several months ago for more money than the jury awarded.

“It is unfortunate that the time spent by the jury and the considerable costs of this trial could have been avoided,” the company said in its statement.

Nehme, a 62-year-old produce merchant and grandfather, said the case was not about money. Before the trial began he pledged to donate any winnings to liver research.

Nehme said he saw the suit as a way to pressure Blue Cross to stop denying out-of-state transplants, adding that he was particularly concerned about patients who could not afford to pay out of pocket.

“I’m trying to save lives,” Nehme said when the trial began Feb. 22. “There are a lot of people who need liver transplants, and they should be able to get them wherever they need them.”

Nehme’s liver began to fail in 2006, and he was placed in line for a transplant at UCLA. Blue Cross readily approved the procedure at the hospital, which is part of its contracted network.

But Nehme’s condition rapidly deteriorated, and his UCLA physician urged him to go to the Clarian Transplant Center in Indianapolis, where he had sent other patients.

At the time, the median wait time for livers at UCLA was more than two years. At Clarian, an Indiana University-affiliated hospital, the wait time was about six weeks.

When Blue Cross refused to pay, Nehme went anyway and picked up the cost of the January 2007 operation.

He recovered and returned to work as the owner of produce markets in the Simi and San Fernando valleys. His suit contended that Blue Cross denied the Indiana transplant to save money.

The verdict arrives as President Obama, stumping for healthcare reform, has been railing against insurance company denials of medical treatment, recalling his mother’s fights with an insurer when she had cancer.

It also comes amid growing outrage over premium increases imposed by Blue Cross and other insurers. Nehme’s premium, for example, increased 50% March 1 to $1,500 a month.