Long-Term Health Care Facility Sues Blue Cross Blue Shield for Claim Denial

A suit was filed Thursday in the Eastern District of Louisiana by plaintiff BridgePoint Healthcare Louisiana, LLC, doing business as BridgePoint Continuing Care Hospital, LLC (BridgePoint) against defendant Blue Cross Blue Shield North Dakota (BCBS). The complaint contains allegations that the defendant violated the Employee Retirement Income Security Act (ERISA) when they failed to approve a claim BridgePoint submitted for medically necessary treatment they had administered from January 9, 2020 to June 10, 2020.

The complaint recounted that on December 26, 2019, a patient (referred to in the complaint as Insured) “required emergency medical treatment at West Jefferson General Hospital.” They were later transferred from West Jefferson to BridgePoint LTAC (long-term care facility) on January 9, 2020. BridgePoint was given pre-approval to treat Insured from the defendant’s agent, Highmark. They were authorized to treat the patient from January 9 to February 6, 2020.

The patient was treated, per court documents, until June 10, 2020 as they developed an infection that necessitated care. BCBS approved the payment of the care up through January 22, but later issued the plaintiff a denial of benefits letter from January 22 onwards stating that the “LTAC stay is denied as not meeting criteria for medical necessity.”

BridgePoint appealed the decision, according to the complaint, reminding the defendant that they had been pre-approved for treatment through at least February 6, and any treatment following that was “necessitated by the Insured having developed an infection during Insured’s stay.” They subsequently provided medical records of Insured to substantiate their appeal. BCBS purportedly denied their appeal and maintained their assertion that the treatment was not medically necessary or appropriate. BridgePoint describes that the defendant “did not provide a specific basis” for the aforementioned claims, despite ERISA requiring that administers of a health care plan must always specify on what basis a claim is denied.

Finally, in May 2021, BCBS acknowledged the necessity of the treatment but explained that they needed additional information before they could process the claim. They did not specify what additional information they needed. When the plaintiff sent a letter questioning what information was needed, BCBS did not respond. Follow-up emails on behalf of the plaintiff yielded no response.

The complaint cites two violations of ERISA, as well as counts of breach of contract, detrimental reliance, negligent misrepresentation, and unjust enrichment. The plaintiff is represented by King, Krebs & Jurgens, PLLC.