Risk & Insurance Online

ANTHEM FOUND GUILTY

Anthem Blue Cross wrongly denied health coverage of a life-saving liver transplant to a grocery store owner even though the operation had been recommended by one of its own physician providers, a Los Angeles jury has found.

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In 2006, doctors told Ephram Nehme, a California grocery store owner and grandfather, he needed a liver transplant to stay alive. Anthem Blue Cross agreed the transplant was medically necessary and authorized it at a California hospital.

But the wait was up to two years, and Nehme's doctor felt he didn't have that much time. So Nehme used his own money to pay an Indiana facility for his $206,000 liver transplant, which Anthem refused to reimburse as it was out of state.

STATE REGULATOR SUED

Pittsburgh-based health insurance carrier Highmark Blue Shield Inc. has sued the Pennsylvania Department of Insurance, alleging its investigation into anti-competitive practices of Pennsylvania health insurers is beyond the purview of the regulator.

Pennsylvania Insurance Commissioner Joel Ario began the investigation into what are known as "The Blues" in July of 2009.

Ario defends the investigation as being well within his realm of responsibilities and the results of it were due out with his report in March.

Other health insurance providers being investigated by Ario's office are the Harrisburg-based Capital Blue Cross and the Wilkes-Barre-based Blue Cross of Northeastern Pennsylvania.

BROKER IN CROSSHAIRS

A lawsuit filed in U.S. District Court in Northern California names BB&T Insurance Services of California Inc., alleging that a broker with the company misrepresented the extent of insurance coverage to a client.

The Burlington Insurance Co. the plaintiff in the case, claims that BB&T broker Masoud Shahri made misrepresentations to taxi companies owned by entrepreneur William Rouse and also conspired to mislead the insurer.

Burlington had agreed to insure Rouse's company, the Administrative Services Cooperative, but not any of its affiliates.

In August 2007, a woman sued an independent contractor hired byRouse's companies, charging him with false imprisonment, sexual assault and battery.

When pressing Burlington to provide a defense, Rouse produced BB&T documents that represented that all of the companies, not just ASC, were covered by the general liability policy.

FM REPORTS ON 2009

Property insurance giant FM Global reported 2009 gross premium in force of $4.7 billion, up 5.6 percent from the year-ago period. Net income was $840 million, compared with a loss of $318 million in 2008.

Policyholder surplus in 2009 grew 35 percent to $6.3 billion, due to a combination of underwriting and investment results, the company also reported.

The company also posted a combined ratio of 69.6 percent, credited to the absence of natural disaster losses and policyholders' risk improvement efforts.

--Compiled by staff from news and wire reports.

May 1, 2010

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