New Lawsuits Allege Patients, Doctors & Hospitals Harmed By Widespread “Retroaction Review” Scheme as Profits Spike 20%

Santa Monica, CA — WellPoint — the nation’s largest health insurer — its subsidiary Blue Cross of California, and Blue Shield were named in 13 new lawsuits today for canceling health insurance policies and refusing to pay medical bills after patients sought treatment.

The new lawsuits build on 10 similar lawsuits filed against Blue Cross and WellPoint three weeks ago by attorney William Shernoff of the Claremont-based firm of Shernoff Bidart & Darras. The lawsuits bring to light a grave threat to patients by companies trying to avoid paying legitimate claims, according to the Foundation for Taxpayer and Consumer Rights (FTCR).

WellPoint announced on Wednesday that its 2006 first-quarter profit increased by 20% in part because the company paid less in medical claims.

“WellPoint is getting fat by breaking its promises to patients. Overturning insurance coverage after patients get sick is a devastating abuse that must stop,” said Jerry Flanagan of the Foundation for Taxpayer and Consumer Rights (FTCR). “These illegal retroactive cancellations make a mockery of health insurance.”

Several patients named in the lawsuits spoke out today at Los Angeles Superior Court about how their health insurance was abruptly canceled, leaving them with huge unpaid medical bills and severe hardship.

“It’s outrageous that health insurers dump policyholders that cost them too much money,” said Michael Norris, a Blue Cross enrollee left with $15,000 in medical bills when Blue Cross retroactively canceled his son’s coverage following a surgery. “Not only does this practice result in huge unpaid medical bills and financial hardship for patients when doctors and hospitals try to collect, it increases emotional stress on the patient and the family when they are most vulnerable.”

According to the lawsuits filed today, WellPoint and Blue Cross of California have created “retroaction review” departments whose sole purpose is to terminate policies for patients who had previously been given approval for medical treatments. An undetermined number of patients — who had been enrolled in policies and paid premiums — have been told that their coverage is retroactively canceled when they seek medical treatment due to purported discrepancies with information provided in their enrollment form.

“The intent of these cases is to stop this widespread unlawful practice that is hurting not only the patients, but is hurting the hospitals and the doctors, and I want to shut that down,” said William Shernoff, attorney for the policyholders.

Under state law HMOs and insurers are prohibited from revoking coverage after claims have been filed (Insurance Code Sec. 10384 & Health & Safety Code Sec. 1389.3) unless they can show that patients intentionally withheld past medical conditions. According to a Los Angeles Times yesterday, in a previous case against the company, a Blue Cross employee admitted that the company routinely canceled policies of sick members after looking for inconsistencies — not fraud as required by law — in their applications. Blue Cross did not investigate whether the alleged omissions were intentional.

“Patients do not go to medical school. Patients do not have the training necessary to decipher technical medical information in their medical records,” said Jerry Flanagan of FTCR. “Insurers have the responsibility to review a patient’s medical records and make coverage decisions before enrolling the patient — not after the patient gets sick.”

In the previous case against the company, Blue Cross employees admitted that they reviewed 1,500 policies a week. Retroactive cancellations were triggered by claims made for certain high-cost illnesses.

Already, unpayable medical bills have bankrupted California families. According to a Harvard Medical School study, in 2005 medical bills were responsible for half of all bankruptcies nationally. Of the approximately 1 million Americans who file for bankruptcy each year as a result of illness, most have college degrees, are working and own their homes. Three-quarters have insurance.

In March, FTCR petitioned state regulators to investigate the practice and use their regulatory authority to shut down the retroactive review department.
Read FTCR’s petitions here.

Blue Cross and Blue Shield patients speaking at today’s press conference included:

• Michael Norris enrolled his son Kyle, 4 at the time, in a Blue Cross insurance plan in December 2004. On June 13, 2005, Kyle underwent a pre-approved surgery to remove a mass of tissue at the back of his throat that could restrict breathing (adenoidectomy). Blue Cross approved surgery to be conducted at Cedars-Sinai Medical Center. In a letter dated December 8, 2005, Blue Cross rescinded Kyle’s health insurance and has refused to pay $15,000 in medical bills. Blue Cross claims that Mr. Norris failed to disclose his son’s ear aches and speech impediment on the enrollment form though such information was readily available to Blue Cross in the information provided by his former insurer, Aetna.
• Howard Bolinger completed the Blue Cross application on July 9, 2002. He disclosed on the application that he had experienced blood in his urine and also disclosed the name of his treating urologist. Blue Cross approved coverage on September 1, 2002. On April 9, 2003, 2005, after receiving authorization from Blue Cross, he had surgery for prostate cancer. Blue Coverage rescinded coverage on July 29, 2003 on the ground that Howard failed to disclose on the application a history of “hematuria.” However, hematuria means blood in urine, a symptom that Howard indisputably disclosed, along with the name of his urologist.
• Parvin Mottaghi completed the Blue Shield application on September 14, 2005. In the application she disclosed that she had respiratory problems, specifically bronchitis. Blue Shield approved coverage on October 1, 2004. On February 24, 2005, Parvin went to the Center for Interventional Cardiology and Nephrology for a nuclear cardiology study. Blue Shield approved the exam. After various cardiology tests and laboratory results, it was determined by her doctors that Parvin’s breathing difficulties resulted from a heart problem and she needed open heart surgery for a defective heart valve. Blue Shield authorized the surgery, which was performed at Cedars Sinai on September 1, 2005. Blue Shield rescinded coverage on March 21, 2006, leaving Parvin with about $100,000 in medical bills.

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The Foundation for Taxpayer and Consumer Rights (FTCR) is California’s leading non-partisan consumer advocacy organization. For more information, visit us on the web at: http://www.ConsumerWatchdog.org.