Family Sues Anthem BCBS After Denial of Benefits

Anthem Blue Cross Blue Shield (ABCBS), a health insurance provider, was sued by a family over claims that the company breached a contract and acted in bad faith when denying health coverage to their minor daughter, who “had been admitted to a long-term, in-patient medical facility.”

According to the filing, on December 22, 2020, the plaintiffs submitted medical bills to the defendant, who was their acting health insurance provider. They submitted the bills on behalf of their daughter, who had accumulated them due to her admission to a long-term care facility. The plaintiffs claim that the medical bills they had submitted in association with the treatment for their daughter were denied in full by ABCBS. They further allege that the company “failed to issue a response or provide a reasonable basis for its inability to issue a response within the 30-day timeline.”

ABCBS claimed that the requested coverage was for treatment that was “medically unnecessary,” yet the plaintiffs said they did little to substantiate this statement. The plaintiffs contended that this denial constitutes a breach of the insurance contract they held with ABCBS, and because of this denial they are experiencing sustained damages. They alleged bad faith, as they argued ABCBS did not complete a thorough investigation of the claim, and it was not given “reasonable evaluation and review.”

According to the complaint, the health insurance provider explained that they deemed the medical treatment as unnecessary because it was “merely a result of poor family dynamics and acting out behaviors.” The medical director for the company added that the plaintiff’s daughter may not have been a genuine risk to herself as the plaintiffs explained because the doctor “had several patients who had threatened suicide multiple times but never actually went through with it.”

After the plaintiffs appealed the denial from ABCBS, they procured “individually written letters from the medical providers previously tasked with caring for the minor daughter, all of whom determined the only option for the safe health and welfare of the Plaintiff’s minor daughter was for her to be placed in a long-term in-patient care facility.” Despite this, throughout the appeal the plaintiffs’ report that the defendants made no attempt to contact any of the family’s medical professionals before denying the appeal for coverage. Ultimately, they contended that there was no reasonable basis for the defendant to deny coverage and that ABCBS “acted in bad faith intentionally for the purpose of delaying and harassing the plaintiffs.”

The plaintiffs are seeking a trial by jury as well as punitive damages. They claimed that because the payment from the insurer is overdue, they are further entitled to an interest of “12% per annum on the amount due and owing.”The plaintiffs are represented by Gruber Law Offices. The defendants are represented by Hansen Reynolds.