Patients sue insurers for denying transplants

Oct 9 2009

The Los Angeles Times has a two-part series on patients who have sued their insurers for denying potentially life-saving transplants.

"Surrounded by supporters, Hilda Sarkisyan marched into Cigna Corp.'s Philadelphia headquarters on a chilly fall day, 10 months after the company refused to pay for a liver transplant for her daughter," The Los Angeles Times reports in one story. Sarkisyan demanded an apology, but was instead was met by employees "heckling her, she said, with one of them giving her 'the finger.'" Initially, the family tried to sue Cigna under "a wrongful-death complaint with the couple contending that Cigna's refusal to cover the transplant led to Nataline's death Dec. 20, 2007, in a case that drew national media attention." But that suit was thrown out by a judge "saying it was barred by a 1987 U.S. Supreme Court ruling that shields employer-paid healthcare plans from damages over their coverage decisions."

A U.S. District judge allowed the family to "pursue damages for any emotional distress caused by the Philadelphia incident" instead. "The ruling was bittersweet for the Sarkisyans and patient advocates, who say it points to the need for federal legislation to allow people to sue health insurers for the life-or-death decisions they make. Under legislation called ERISA, "which governs employee retirement funds and benefit plans," "[t]he cost of mounting a lawsuit often far exceeds the cost of the treatment in question, patient lawyer Scott Glovsky said. As a result, few lawyers take them on. That has in effect shut the courthouse doors on most treatment coverage disputes involving workplace health plans, which are the source of medical insurance for 132 million workers and dependents." (Girion, 10/8).

In an earlier story, The Los Angeles Times reports on Ephram Nehme, a California man who paid $200,000 for his own liver transplant surgery in Indiana, "where wait times for organ transplants are far shorter than in California." His "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," although the insurer had agreed to pay for the transplant in California.

"The case offers a rare glimpse into the life-and-death decisions insurers make behind closed doors ... 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." But Nehme's case accuses Anthem "of reflexively denying" the request for a transplant in Indiana, then "rubber-stamping that decision in a series of hasty and inadequate reviews conducted by physician-employees without training in transplant specialties." In a statement, Anthem defended its procedures, saying they review "all transplant requests 'on a case by case basis by a medical expert'" (Girion, 10/7).