Ephram Nehme was gravely ill when Anthem Blue Cross of California agreed to pay for a liver transplant his physician said he needed to survive. Then, his condition went downhill fast.
The news from his doctor was bad. The word from his insurer was worse.
Nehme's doctor told him he could die waiting for an organ in California and urged him to go to Indiana, where the waiting list was shorter. But Anthem Blue Cross said no. It would not pay for a transplant in Indiana.
Nehme, a Lebanese immigrant with a rags-to-riches story, could afford to buy himself a new lease on life and did -- going to Indiana and paying $205,000 for a liver transplant there.
But he remains angry with Anthem and sued the company, accusing it of putting its bottom line ahead of his medical needs.
"I hope I can change it for other people," said Nehme, 61, who runs produce markets in the San Fernando Valley and Simi Valley. "If somebody doesn't have a nickel in his pocket, what happens? He's dead."
The case offers a rare glimpse into the life-and-death decisions insurers make behind closed doors and illustrates one of the most emotional questions in healthcare: Who should decide what is best for a patient -- doctors or insurers?
"This is a tremendously important issue because most people aren't savvy enough about how to work this system, and it is totally stacked against them," said Bryan Liang, director of the Institute of Health Law Studies at California Western Law School in San Diego. "The insurers make sure they get the results they want. They hold all the cards."
Insurers say their pre- authorization reviews of big-ticket procedures, such as transplants, play important roles: ensuring that patients get the care they need, when they need it, and keeping a lid on costs.
In Nehme's case, Anthem says it did nothing wrong. It contends that his policy made it clear that transplants were covered only at certain contracted hospitals, and that he was not sick enough to qualify for an exception.
"Mr. Nehme was placed on a waiting list by his treating physicians for organ donation at UCLA but sought approval for transplant services at a different facility that was not within our transplant network," WellPoint Inc., Anthem's Indianapolis-based parent company, said in a statement.
"Upon additional third party review," the company said, "it was determined that Mr. Nehme's condition did not present medical urgency to require an emergency [out-of-network] transplant."
