BCBS of New Mexico Improper Denials of Care New Mexico Class Action

Health insurance companies may refuse to authorize novel or unproven treatments, or procedures that don’t meet their guidelines. However, the complaint for this class action alleges that Blue Cross and Blue Shield of New Mexico, a company of Health Care Service Corporation, routinely refuses patients services and forces them to go through appeal processes, to discourage them from receiving services.

New Mexico calls its Medicaid program Centennial Care. It contracts with Blue Cross Blue Shield (BCBS) of New Mexico to provide certain benefits to Medicaid recipients. The plaintiff in this case, Julie Graham, was enrolled in BCBS’s Blue Cross Community Centennial program.

Graham suffers from acute and chronic pancreatitis, for which she was hospitalized repeatedly in 2019 and 2020.

The complaint alleges, “Plaintiff’s Graham’s surgeons and gastrointestinal specialists at the University of New Mexico recommended a total pancreatectomy with islet cell autologous transplantation (‘TP-IAT’). That beneficial procedure, however, was not available in New Mexico at the time, or for the rest of 2020.” Graham attempted to be treated in Texas, but the procedure was not available there either.

Graham then tried to get authorization to have the procedure done at Virginia Commonwealth University (VCU) Health Systems in Richmond, Virginia. The complaint alleges, “Under Medicaid federal and state laws, rules, and regulations, and the Contract [between Medicaid and BCBS of New Mexico], Plaintiff Graham was entitled to this medical care that she requested, and entitled to have that care provided at VCU.”

However, the complaint alleges that BCBS refused to provide that authorization, forcing Graham to file an internal appeal. BCBS denied the appeal, which the complaint claims forced her to file an administrative appeal with the Fair Hearings Bureau.

Before the judge could begin to take evidence, however, the complaint claims, “Defendant BCBS … agreed to provide the requested authorization, causing the appeal to be dismissed. Defendant BCBS thus avoided scrutiny by the State’s administrative law judge of its prior denials of care.”

According to the complaint, BCBS’s initial denials of care were based on false and misleading statements about the care Graham wanted or should receive and about its own obligations in providing that care.

The complaint alleges, “Through its tactics and business practice of improperly or wrongfully denying authorization for medical care, Defendant BCBS engages in a pattern and practice of discouraging claimants, and of denial and delay of care, to increase its profits.”

The class for this action is all citizens of New Mexico who were participants in the BCBS Blue Cross Community Centennial program and who have been denied benefits or reimbursement for goods or services for which they were eligible under the program, who then requested an appeal of those denials, suffered a denial, subsequently requested a Fair Hearing, where BCBS then reversed its denial of the appeal, causing the Fair Hearing Bureau appeal to be vacated or dismissed.

Article Type: Lawsuit
Topic: Insurance
Tags: Breach of Contract, Breach of the Covenant of Good Faith and Fair Dealing, Denial of Benefits, Health Insurance, Insurance