Blue Cross Blue Shield sued over adjusted insurance policy

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Memorial Hermann Health System (Memorial Hermann) filed suit against defendant Blue Cross Blue Shield of Texas on Thursday in the Southern District of Texas. The lawsuit claims that the defendant health insurance company “prioritized profits over the welfare of patients and its obligation to pay for emergency and subsequent care.”

Plaintiff claims that Defendant lost hundreds of millions of dollars due to the Affordable Care Act Exchange Plans and Individual Market Plans in 2013 and 2014. In an effort to offset these losses, the BCBS allegedly began a practice of “falsely denying hundreds of Blue Advantage and MyBlue Health claims for emergency services and post-stabilization care,” including those the plaintiff had filed.

While a lawsuit in 2017 resolved much of the misconduct, the defendant once again reportedly refused to properly reimburse the plaintiff for the claims, which would have caused Memorial Hermann $3 million in damages.

After losing more than $400 million, the defendant only approved claims it considered emergency Hermann Memorial care, believing it was because it had classified the plaintiff as out-of-grid. The defendant also explained that the plaintiff must compel the members of BCBS insurance to leave Memorial Hermann and be transferred to a network classified hospital, “even if it disrupts the continuity of patient care, endangers the safety of the patient and subjects Memorial Hermann to potential liability for improper transfers or medical malpractice.

When the defendant changed its policy, it went from about one claim denial per month to an average of 40 per month. Plaintiff claims he was financially harmed by BCBS’s misconduct while Defendant was unjustly enriched. They also state that the BCBS is endangering patient care and safety through their policy.

The complaint cites express breach of contract, implied breach of contract, quantum meruit, promissory estoppel, unjust enrichment and declaratory judgment. Plaintiff seeks actual damages, interest, court costs, a jury trial, and any other relief deemed fair by the Court.

Plaintiff is represented by Smyser Kaplan & Veselka, LLP.

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