Managed Care Litigation Update Volume 47: December 31, 2015

• Jurisdiction: United States,Federal
• Publication year: 2015
• Citation: Vol. 47

Newsworthy

Health insurers face fines beginning January 1, 2015 for inaccuracies in Medicare Advantage directories and for plans sold on federal exchanges. http://www.wsj.com/articles/health-insurers-to-face-fines-for-not-correcting-doctor-directories-1451335323

In putative class action contending Aetna improperly capped benefits for treatment of autism, Court finds arbitration clause in Enrollment Request mandates arbitration. Ortiz v. Aetna Health of CA, USDC No. 15-03334, Doc. No. 24 (Dec. 22, 2015). See also MCLU Vol. 37.

States largely denying coverage for Harvoni under Medicaid citing high cost. http://www.npr.org/sections/health-shots/2015/12/27/460086615/states-deny-pricey-hepatitis-c-drugs-to-most-medicaid-patients

Insurers' efforts to discourage prescriptions for certain drugs by applying high copayments thwarted by coupons issued by drug companies. http://www.bloomberg.com/news/articles/2015-12-23/that-drug-coupon-isn-t-really-clipping-costs

Recently filed actions

Jean-Paul Poirier v. Aetna Health of Utah, Inc., et al., U.S.D.C. D. UT, Doc. No. 2:15-cv-00886-BCW, (filed Dec. 16, 2015). Action by member against claims administrator and self funded plan to recover $15,561.37 in benefits for treatment rendered by IHC Health Services, Inc., Intermountain Medical Center. Denial based on lack of prior authorization, although plaintiff alleges the treating physician received such authorization.

Weldonna Drew v. Anthem Blue Cross Life and Health Insurance Company, U.S.D.C. C.D. CA, Doc. No. 2:15-cv-09706, (filed Dec. 17, 2015). Member seeks coverage from Anthem Blue Cross for Harvoni to treat Hepatitis C, contending that denial based on lack of sufficient liver scarring to justify coverage was improper. Similar claims seeking coverage for this drug reported at MCLU Vol. 33, 34, 37, 38, 43, 45, and 46.

Adam A. Marfice v. Blue Cross of Idaho Health Services, Inc., U.S.D.C. D. ID, Doc. No. 2:15-cv-00585-CWD, (filed Dec. 17, 2015). Removed action in which member seeks recovery of benefits for surgical excision of the gynecomastia and treatment for subsequent complications. Plaintiff alleges all of the treating providers were contracting providers with Blue Cross and that services were preauthorized or that preauthorization was not necessary. Basis for denial is not stated in underlying Complaint.

Rensol Corporation, et al. v. Blue Cross Blue Shield of Michigan, U.S.D.C. E.D. MI, Doc. No. 1:15-cv-14385-TLL-PTM, (filed Dec. 18, 2015). Plan sponsor contends BCBS Michigan, as administrator of its self funded plan, skimmed additional administrative fees from Plan assets and seeks recovery of allegedly misappropriated funds. Near identical cases reported in prior MCLU issues.

SEE ALSO:

• Duncan Aviation, Inc., et al. v. Blue Cross Blue Shield of Michigan, U.S.D.C. E.D. MI, Doc. No. 2:15-cv-14389-DPH-RSW, (filed Dec. 18, 2015).
• Moka Corporation, et al. v. Blue Cross Blue Shield of Michigan, U.S.D.C. E.D. MI, Doc. No. 2:15-cv-14399-PDB-EAS, (filed Dec. 21, 2015).
• Brazeway, Inc., et al. v. Blue Cross Blue Shield of Michigan, U.S.D.C. E.D. MI, Doc. No. 2:15-cv-14474-PDB-APP, (filed Dec. 28, 2015).

Timothy McConnell v. Anthem Blue Cross Life and Health Insurance Company, U.S.D.C. C.D. CA, Doc. No. 2:15-cv-09785-RGK-AJW, (filed Dec. 21, 2015). Member seeks coverage from Anthem Blue Cross for Harvoni to treat Hepatitis C, contending that denial based on lack of sufficient liver...