Managed Care Litigation Update Volume 98: February 15, 2018

• Jurisdiction: United States,Federal
• Publication year: 2018
• Citation: Vol. 98

Newsworthy

U.S. Ninth Circuit holds Blue Shield of California did not abuse its discretion "when it determined that partial hospitalization, and not ongoing residential treatment, was the most appropriate level of care under the Plan" for woman suffering from anorexia nervosa. Krysten C. v. Blue Shield of California, U.S. Ninth Cir. No. 16-16958 (01/09/18, unpubl.). See also MCLU Vol. 34.

District Court holds that even though plaintiff's ADR surgery falls within the scope of Experimental and Investigational Exclusion, Anthem waived its right to deny the claim after it had approved the claim. Cohorst v. Anthem Health Plans of Kentucky, Inc., U.S.D.C. C.D. CA, No. 16-7925 (Doc. 43, 12/12/17). See MCLU Vol. 67.

Putative class action in which plaintiffs allege AARP acts as de facto agent for UnitedHealth, improperly collecting commission on AARP Medigap policies and thereby violating the Florida Insurance Code. Sacco v. AARP, Inc., et al., U.S.D.C. SD FL, No. 18-14041 (02/08/18, Doc. 1.)

Recently filed actions

Jeffrey March v. [ ] and Blue Cross Blue Shield of Michigan, U.S.D.C. W.D. MI, Doc. No. 1:18-cv-00114-JTN-ESC, (filed Feb. 2, 2018). Member seeks declaration of right to benefits and priority of coverage under ERISA and Michigan's No Fault Act as between his auto insurer and his health insurer, BCBS Michigan, associated with personal injuries sustained in a motor vehicle accident. Actions involving similar claims reported in MCLU Vol. 24, 25, 32, 38, 48, 49, 54, 67, 68, 92, 94

NCG Chantilly, LLC v. Anthem Health Plans of Virginia, Inc., U.S.D.C. E.D. VA, Doc. No. 1:18-cv-00114-AJT-JFA, (filed Feb. 1, 2018). Provider of in-center hemodialysis services contends it provided dialysis services to an Anthem insured, where Anthem is alleged to have "agreed to reimburse NCG for the Dialysis Services that NCG provided to the Insured at a rate equal to seventy percent (70%) of NCG's standard rate ..." "ANTHEM has paid NCG only a fraction of the invoice amounts ..." and owes $126,739.23. Basis for payment made is not stated in Complaint

IHC Health Services, Inc. dba Intermountain Medical Center v. [ ] and Coventry Healthcare of Georgia, Inc., U.S.D.C. D. UT, Doc. No. 2:18-cv-00111-BCW, (filed Feb. 5, 2018). Hospital and alleged assignee seeks recovery of $101,986.12 for services rendered, where billed charges totaled the same amount and "[t]he Defendants have only paid $0.00 ..." "The Defendants denied the claim, asserting that the treatment lacked preauthorization." Plaintiff alleges that the patient "was admitted to the hospital for neurological monitoring and treatment as indicated [for injuries associated with a skiing accident]." Multiple lawsuits by this provider against major carriers reported in prior MCLU issues.

SEE ALSO (similar allegations, different patient):

• IHC Health Services, Inc., dba Intermountain Medical Center v. [ ] and Anthem Blue Cross Life and Health Insurance Company, U.S.D.C. D. UT, Doc. No. 2:18-cv-00119-PMW, (filed Feb. 6, 2018).

Robert Giglio v. Cigna Life andHealth Insurance Company, et al., U.S.D.C. D. NJ, Doc. No. 3:18-cv-01499-MAS-LHG, (filed Feb. 2, 2018). Removed action in which plaintiff alleges his son "incurred medical expenses in the amount of $49,586.00 in connection with various medical treatment and procedures relating to Temporomandibular Joint Dysfunction" but that "defendants have failed and refused to make payment ... " Basis for non-payment is not stated in underlying Complaint for Declaratory Judgment.

Jatera Williams v. Cigna Health and Life Insurance Company, U.S.D.C. E.D...