Anthem Denies Insurance Coverage for Emergency Services, Class Action Says

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A class action lawsuit alleges that Anthem Inc. and Anthem UM Services Inc. wrongly deny insurance coverage for emergency services.

Plaintiff Justin Marmor says that he had insurance benefits through his employer, provided by Anthem, and that those benefits included coverage of emergency services.

Marmor claims that on April 15, 2018, he was seen at an emergency room of Cedars Sinai hospital. He says it was discovered that he had a condition that required emergency services, and was admitted to the hospital.

Marmor alleges that later he received a letter saying that his coverage had been denied.

Anthem UM reportedly notified him that the insurance company was refusing to pay for both his emergency treatment and his stay in the hospital.

However, Marmor says that Anthem only provided an explanation for why they were denying coverage for his hospital stay. Allegedly, the company did not delineate why they refused to pay for his emergency services.

The Anthem emergency coverage class action lawsuit says that Marmor sent a letter to Anthem on July 5, 2018, notifying them that he was appealing the decision.

He says that on Aug. 2, 2018, he received a letter saying that his appeal for benefits related to his hospitalization had been denied, but the letter failed to address Marmor’s appeal of the denial of emergency services benefits.

The Anthem emergency services coverage class account lawsuit argues that Anthem makes a company-wide practice of wrongly denying coverage for emergency services.

Allegedly, the company does not provide sufficient explanations for why coverage was not granted, but after the services have been provided and emergency treatment has been given, the company determines that the services were “non-emergent” or not required because of an emergency.

To support the claim that Anthem wrongly denies emergency services coverage, and knowingly does this, the Anthem class action lawsuit cites an investigation by the Office of United States Senator Claire McCaskill into the company’s policies.

McCaskill’s office reportedly determined that Anthem had “implemented a policy to deny reimbursement for claims for emergency room (ER) services related to conditions it later deems non-emergent.”

In light of this investigation, the company allegedly admitted to McCaskill that it did use a series of diagnostic codes “that are not often associated with emergency care” and when one of the services associated with those codes are used, a review of the services are triggered, with the goal being to determine if the services were provided for an emergency condition.

However, the company allegedly provided incomplete information to McCaskill’s office for the investigation.

Marmor says that in his case, and in the case of many other patients, Anthem “failed to establish reasonable claims procedures for handling emergency services claims.”

The plaintiff goes on to allege that in reviewing cases in the way the company does, the company effectively forces patients who are in an emergency situation to “self-diagnose themselves before seeking emergency services” to determine what care they might need.

He claims that this policy is unreasonable and unachievable by the average patient in distress seeking emergency care.

Marmor is represented by Robert S. Gianelli, Joshua S. Davis, and Adrian J. Barrio of Gianelli & Morris.

The Anthem Emergency Services Coverage Denial Class Action Lawsuit is Justin Marmor v. Anthem Inc., et al., Case No. 2:18-cv-08157-CAS-MAA, in the U.S. District Court for the Central District of California.