On April 8, 2013, a Los Angeles jury awarded $3.8 million in compensatory damages to an urgent care and family practice physician who claimed he was wrongly excluded from Anthem Blue Cross’s provider network. Anthem Blue Cross is a unit of the insurance giant WellPoint Inc. It is expected that this rare verdict will very likely encourage other doctors to challenge health insurance companies’ decisions in the future.
To review the case summary, click here.
We note that this case occurred in California. Doctors have been very successful in lobbying the legislature to maintain certain rights that no longer are afforded to physicians in many other states. Additionally, the trial courts are often more liberal at accepting courses of action that courts in other states don’t recognize.
Physician Claims Anthem Blue Cross Retaliated Against Him for Being a Patient Advocate.
The physician sued Anthem Blue Cross in 2010, after the health insurance company barred him from its professional provider network, according to the Los Angeles Times. In rejecting his application, the health insurer said it had no need for another general practitioner in its network. The physician claims he was excluded because he was a strong patient advocate. Previously, as a member of the Anthem Blue Cross network, the doctor would often challenge the insurer’s denials of patient claims. The Los Angeles Times article states the doctor would even meet with top Anthem officials over these denied claims.
This lawsuit was brought under the fair procedure law in California. This law requires that an insurer’s decision to exclude a physician be rational and not arbitrary or against public policy.
To read the entire Los Angeles Times article, click here.
Many doctors find themselves in similar positions, terminated from an insurance panel without cause.
Anthem Blue Cross’s Case.
According to an article on Reuters, Anthem Blue Cross contends the decision to exclude the physician was based on a board certification issue. The insurer alleges that in 2009, the physician applied to be included in the network in the family and emergency medicine categories, even though his board certification in emergency medicine had expired. The physician supposedly changed his listed specialty to general medicine. In court, Anthem Blue Cross argued it had 137 primary-care physicians in its network in the physician’s geographic area. However, at trial it is reported that the insurance company could only name seven of those in-network physicians, thus refuting the credibility of the insurance company.
Click here to read the article on Reuters.
Punitive Damages Settled.
On April 11, 2013, it was reported by the Los Angeles Times that Anthem Blue Cross and the doctor reached a confidential settlement over punitive damages. This agreement kept the jury from imposing additional punitive damages against Anthem Blue Cross. It’s reported neither the plaintiff nor defendant would discuss the terms of the settlement.
Jury’s Decision Rare and Expected to Stir Up More Litigation.
Insurers are increasingly cutting their lists of medical providers and promoting smaller networks. The insurance companies then try to negotiate lower rates with the fewer providers left in the network, who get higher patient volume in return.
This jury’s verdict is expected to encourage other providers excluded from health plans to come forward. Exclusion from a health care plan can be extremely costly for a provider. This decision also serves as a reminder to health insurance companies that any decision to reject or terminate a provider’s application should be well documented to show a legitimate reason.
Successful Litigation is Possible - If You Have the Money.
This case shows that often the physician can succeed against a large insurer if he or she chooses to sue it. However, such cases are expensive, many doctors do not have the financial resources to pursue them, and there is a significant risk of failure. However, remember: “no pain, no gain.”
Contact Experienced Health Law Attorneys.
The Health Law Firm routinely represents pharmacists, pharmacies, physicians, nurses and other health providers in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving the Drug Enforcement Administration (DEA), Federal Bureau of Investigation (FBI), Department of Health (DOH) and other law enforcement agencies. Its attorneys include those who are board certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.
To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.
Do you think this case will encourage other physicians, who believe that they were wrongly terminated or rejected, to challenge health insurance companies? Please leave any thoughtful comments below.
Terhune, Chad. “Anthem Blue Cross Settles with Doctor, Avoids Second Jury Award.” Los Angeles Times. (April 11, 2013). From: http://www.latimes.com/business/money/la-fi-mo-anthem-doctor-settle-20130411,0,6186940.story
Terhune, Chad. “L.A. Jury Sides with Doctor in Anthem Blue Cross Case.” Los Angeles Times. (April 10, 2013). From: http://www.latimes.com/business/la-fi-anthem-doctor-verdict-20130410,0,2796259.story
Baynes, Terry. “Doctor’s $3.8 Mil Win Sends Warning to Health Plans.” Reuters. (April 10, 2013). From: http://newsandinsight.thomsonreuters.com/Legal/News/2013/04_-_April/Doctor_s_$3_8_mln_win_sends_warning_to_health_plans/
About the Authors: Michael L. Smith, R.R.T., J.D., is Board Certified by The Florida Bar in Health Law. He is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.
George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.
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