Blue Cross Blue Shield Sued Over Adjusted Insurance Policy

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 complaint claims that the defendant health insurance company was “prioritizing profits over patient well-being and its obligation to pay for emergency and subsequent care.”

The plaintiff asserts that the defendant lost hundreds of millions of dollars due to Affordable Care Act Exchange plans and individual market plans in 2013 and 2014. In an effort to make up for these losses, BCBS allegedly began a practice of “wrongly denying hundreds of valid Blue Advantage and MyBlue Health claims for emergency services and post-stabilization care,” including those that the plaintiff had filed.

While a 2017 lawsuit resolved much of the misconduct, the defendant is allegedly once again refusing to properly reimburse the plaintiff for the claims, which has purportedly caused Memorial Hermann $3 million in damages.

After losing more than $400 million, the defendant only approved claims that they deemed as emergency care form Memorial Hermann, reasoning that it was because they classified the plaintiff as out-of-network. The defendant also explained that the plaintiff must force members of BCBS insurance to leave Memorial Hermann and transfer to a hospital that was classified as in-network, “even if it disrupts the patient’s continuity of care, endangers patient safety, and subjects Memorial Hermann to potential liability for improper transfers or medical malpractice.”

When the defendant changed their policy, they went from around one claim denial per month to an average of 40 per month. The plaintiff asserts that they were financially injured by BCBS’s misconduct while the defendant was unjustly enriched. They also state that BCBS put patients care and safety at risk through their policy.

The complaint cites breach of express contract, breach of implied contract, quantum meruit, promissory estoppel, unjust enrichment, and declaratory judgment. The plaintiff is seeking actual damages, interest, litigation fees, a trial by jury, and any other relief deemed equitable by the Court.

The plaintiff is represented by Smyser Kaplan & Veselka, LLP.