Plaintiff Claims His Surgery Should Be Covered Despite Unapproved Transfer

On Friday a case was filed in the Central District of California by Dr. Steven Villalobos against Blue Shield of California Life and Health Insurance Company regarding the coverage of urgent surgery after the defendant claimed that it should not be covered. 

The plaintiff was a member of a Health Maintenance Organization (HMO) Employee Retirement Income Security Act plan that was administered by Blue Shield and his Primary Care Physician group was HealthCare Partners Medical Group (HPMG). 

HMO coverage seeks to contain the costs of healthcare by using primary care doctors to “pre-screen” treatments and only approve the medically necessary ones instead of those performed for the convenience of the patient or the treating physician. This sometimes results in HMO primaries declining to cover a particular location for procedures due to cost, approving instead a lower level facility that has a more favorable contract with the health plan. However, this decision is not supposed to be based solely on costs, but on the medical needs of the patient.

The plaintiff reportedly went to the Inter-Community Medical Center (“ICMC”) with a non-healing foot wound that was infected. After receiving medication and debridement to clean the wound, it was apparent that a more drastic procedure involving amputation would be required. The two vascular surgeons provided by HPMG at ICMC both recommended at a minimum a partial foot amputation which would likely require a below knee amputation if there were complications. 

Dismayed at this, the plaintiff sought a transfer to a higher level hospital with a specialist in vascular salvage, which was denied. The patient then checked out and went to the higher level facility anyway, where the procedure was performed and the majority of the patient’s foot was retained. However, HPMG declined to approve the transfer, demanded that the patient be transferred back to the original facility prior to the procedure, and declined to cover the procedure when it was performed anyway. 

While the health plan has covered some of the aftercare, the plan has not processed the main procedure, indicating that it was not authorized and is non covered.

The plaintiff is suing for payment of the procedure under a breach of contract theory and for equitable relief. The plaintiff is represented by the Russell G Petti Law Offices.