Anthem Blue Cross of California was ordered today to pay $206,000 to a man who alleged he had to finance his own operation or die waiting to have it done at a location approved by the health insurer.
Ephram Nehme, 62, alleged in his lawsuit filed in August 2008 that Blue Cross broke a contract by refusing to compensate him because he had liver transplant surgery outside their network of providers.
The jury, after deliberating for 1 1/2 days, agreed with the plaintiff. But the panel also found the company did not act with malice, depriving Nehme of any punitive damages.
Nehme's lawyer, Scott C. Glovsky, was not immediately available for comment on the jury's decision.
He maintained during the trial that Blue Cross put its concern for profit ahead of the life of one of its insured. Had Nehme waited for surgery at UCLA instead of traveling to Indiana -- where the waiting list was shorter -- he would have died, Glovsky said.
Blue Cross spokeswoman Peggy Hinz said the company accepts the verdict.
"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 malice toward Mr. Nehme,'' Hinz said.
Months ago, Blue Cross offered a settlement to Nehme larger than the award he received today, according to Hinz.
During opening statements, defense attorney William E. von Behren said Blue Cross told Nehme he could go out of state to have his transplant performed sooner, as long as he went to a hospital approved by the insurance company.
The Indiana University location, Clarian Transplant Center, did not meet the company's standards at the time Nehme wanted his transplant performed, according to von Behren.
After Blue Cross' initial denial, the company heard three appeals by Nehme and the same conclusion to deny payment was reached, 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 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.
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 charged.
Nehme received a liver transplant in Indiana in January 2007, Glovsky said.
Glovsky was sharply critical of Blue Cross' evaluation process in deciding who should be compensated for transplant surgeries done outside their network. It all comes down to cost, he said.