California jury rules insurer should pay for out-of-state operation; Mass. probe shows insurers' payments can vary widely

The Los Angeles Times: "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."

One of Nehme's lawyers said he would ask the judge to order the insurer 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." An Anthem Blue Cross spokesperson said, "'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,'" (Girion, 3/15). 

The Boston Globe: "Newly released documents from a major insurer detail how certain hospitals and doctors are paid dramatically more than others for the same types of services, sometimes as much as three times higher. The vast inequalities emerged in documents filed by Harvard Pilgrim Health Care Inc., the second largest health insurer in Massachusetts, before the start today of state hearings investigating why health care costs are rising so rapidly. Written testimony from Harvard Pilgrim discloses which of the hospitals and physician groups in its network are the best paid and which are paid the worst. The hospitals that commanded the highest fees for inpatient care in 2008 include powerhouses like Children's Hospital Boston, Dana-Farber Cancer Institute, and the major Partners Healthcare hospitals, Massachusetts General and Brigham and Women's, according to the insurer" as well as some smaller community hospitals" (Kowalczyk, 3/16).

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This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.