Blue Cross sued for Cost of Transplant

Los Angeles - Blue Cross of California should pay the $205,000 cost of a liver transplant for a man who went to Indiana for surgery because the wait in California would have been fatal, a lawyer said in the opening statements on Monday in the suit against the insurer.

Scott Glovsky addressed a Los Angeles Superior Court jury on behalf of 62-year-old Ephram Nehme, who alleges breach of contract. Glovsky said Nehme had to pay for the transplant because he would have died without it.

"Ephram went out of state ... to save his life," Glovsky said.

Blue Cross attorney William von Behren told jurors there is no medical evidence Nehme would have died had he waited to have his surgery at UCLA. By going out of the Blue Cross coverage network, he left the insurer with no obligation to pay for his out-of-state care, von Behren said.

"No ... doctor told him to go elsewhere or die," von Behren said.

According to Glovsky, Nehme had a rapid progression of his liver disease in 2006 that originated with a tainted blood transfusion. His nurses and doctors, including UCLA hepatologist Dr. Sammy Saab, recommended that he travel to Indiana University because they doubted he could get a transplant within a reasonable time at the Westwood medical center, Glovsky said.

However, Blue Cross made an administrative decision in November 2006 denying authorization of the Indiana surgery without doing an investigation or talking with any of his treating physicians, Glovsky said.

Nehme received a liver transplant in Indiana in January 2007, Glovsky said.

According to von Behren, Nehme was told he could go out of state to have his transplant performed sooner if he went to a medical center approved by Blue Cross.

The Indiana University location, Clarian Transplant Center, did not meet the company's standards at the time Nehme wanted his transplant performed.

After Blue Cross' initial denial, the company heard three appeals by Nehme and the same conclusion to deny payment was reached, von Behren said.

Dr. Zeinab Dabbah, the former Blue Cross medical director who originally denied Nehme's claim, was the trial's first witness. Cross-examined by Glovsky, she defended her decision and said she viewed herself more as a champion of Blue Cross members than a proponent for the company.

Asked by Glovsky if she was acting in Nehme's best interests when she issued the denial in his case, Dabbah replied affirmatively.

At a news conference organized by the group Consumer Watchdog and held on the downtown courthouse steps during a break in the court proceedings, Nehme said he wants to speak on behalf of others in similar situations, but unlike him do not have the ability to pay for expensive health care.

"I came back here to fight for the people standing in line," Nehme said.

Anthem Blue Cross recently announced rate hikes up to 39 percent for Californians with individual health care policies, Consumer Watchdog spokesman Jerry Flanagan said during the news conference.

Consumer Watchdog bills itself as a non-profit advocate of insurance and health care reform.