Anthem Caves in Spine Surgery Lawsuit. Must Pay.

Between August 2013 and August 2016 Anthem, Inc., one of the largest medical insurers in the United States, categorically DENIED all requests to reimburse two-level cervical artificial disc replacement surgery (2C-ADR) because, they said, it was “investigational.”

In July 2017, Lawrence Bradford filed a class action suit against Anthem Inc. on behalf of all similarly situated plaintiffs, seeking declaratory and injunctive relief. Bradford claimed that Anthem categorically denied all requests for two-level cervical artificial disc replacement (2C-ADR) surgery because the procedure was “investigational.” Failing to state a specific reason or reasons for denying claims and failing to provide the specific plan provisions on which a determination is based is a violation of the Employee Retirement Income Security Act of 1974 (ERISA).

Because Anthem failed to state a specific reason or reasons for labeling cervical artificial discs as “investigational” and therefore denied claims and failed to provide the specific plan provisions on which a determination was based, claimed Bradford, is a violation of ERISA.

The two parties mediated and came to a settlement.

According to the terms of the settlement, all class members (“class members” are defined as patients who were denied two-level cervical artificial disc treatment from August 2013 when the FDA approved the surgery to August 2016 when Anthem began to cover the surgery) who paid out-of-pocket for 2C-ADR can make claims for reimbursement and class members who have not yet undergone 2C-ADR and are still covered by Anthem can submit their requests for approval. Anthem will reimburse class members for out-of-pocket expenses up to a maximum of $35,000. Anthem also agreed to pay the class counsel’s attorney fees.

But Anthem was not done playing games.

The massive insurance company decided to notify patients who’d been denied treatment by first class mail.

The terms of the settlement did not specify how patients were to be notified, it only said that the proposed settlement be mailed no later than 28 days after the entry of the preliminary approval order.

Back to court the attorneys went, and a federal court judge just ruled that Anthem, Inc. cannot use first class mail to notify the members of class about a spinal surgery settlement.

Judge Andre Birotte, Jr. of the United States District Court for the Central District of California said that notifying a class by a single piece of first-class mail was inadequate.

Judge Birotte ordered Anthem to at least use Priority Mail Flat Rate Envelopes and mark the envelopes with “attention-getting text” to maximize the likelihood that the class members would pay attention to the notice.