PALMDALE – Anthem Blue Cross is being sued by a local sheriff’s sergeant and his wife because the insurer allegedly denied the lawman more than $1 million in hospital stay benefit coverage after he failed to awake from anesthesia while undergoing surgery to have a piece of meat removed from his esophagus.
The complaint was filed last week in Los Angeles Superior Court by Palmdale resident Melissa Williams on behalf of herself and as the guardian for her husband, Sgt. Glen Williams. The suit alleges Anthem found that Williams’ hospital stay claim lacked medical necessity.
The suit alleges breach of contract and both negligent and intentional infliction of emotional distress. It seeks unspecified compensatory and punitive damages.
Anthem spokesman Darrel Ng did not immediately reply to an email seeking comment.
According to the lawsuit, Williams began working for the Los Angeles County Sheriff’s Department in 1985 and was promoted to sergeant in 2011. He and his wife celebrate their 30th anniversary this year and have three children, all in their 20s.
Williams was 53 years old and was eating dinner with his family on New Year’s Day 2014 when the meat became lodged in his esophagus, the suit states.
He underwent surgery the next day at Antelope Valley Hospital, the suit states.
“Immediately before Glen underwent the… he called Melissa to tell her he loved her,” the suit states. “But after being placed under anesthesia, Glen did not wake up and currently remains in an incapacitated state.”
Williams spent a month in intensive care at Antelope Valley Hospital before being transferred to Kindred Hospital for another three months, the suit states. He was transferred in April 2014 to Providence Holy Cross Medical Center in Mission Hills, where he remains today, the suit states.
Four weeks after Williams arrived at Holy Cross, Blue Cross began denying benefits for his continued stay, the suit alleges.
Blue Cross approved Williams’ stay from Jan. 13 to Feb. 14, as well as Feb. 14 to March 16, but not for any other days after last June 23, according to the lawsuit.
“Thus, plaintiffs are responsible for medical expenses through Dec. 3 in a sum of $1.05 million and have continued to incur daily expenses in the sum of approximately $6,500 since Dec. 3, with the exception of the random two-month period approved by Blue Cross without explanation,” the suit states.
Melissa Williams was forced to apply for Medi-Cal benefits for her husband even though she continues to pay Blue Cross premiums and would rather not have assistance from taxpayers to pay his hospital bills, the suit states.
“In reaching the conclusion that Glen’s continued stay at Holy Cross was not medically necessary, Blue Cross relied on a clinical guideline for skilled nursing facility services which was not attached to or disclosed in the evidence of coverage,” the suit states. “By ignoring the definition of medical necessity in the evidence of coverage, and using a different definition undisclosed to plaintiffs, Blue Cross has breached the expressed and implied obligations it owed plaintiffs under California law.”
Since arriving at Holy Cross, Williams has breathed through the tracheostomy in his neck and received “aggressive tracheostomy care and suctioning at least every four hours,” the suit states. “He also receives regular breathing treatments on the same schedule.”
Williams suffers from deep vein thrombosis, in which blood clots form in one or more of his deep veins, and he is constantly monitored for pressure sores, the suit states. He is “at high risk” for pneumonia and urinary tract infections, the suit states.
Several photographs of Williams with his family before he became ill are attached to the lawsuit.
A case management conference has been set for Aug. 12, 2015, at the Stanley Mosk Courthouse in Los Angeles.
2 comments for "Anthem Blue Cross sued for denying insurance benefits to sheriff’s sergeant"
Cali Palmdale says
Hopefully he recovers. And just to think this story was made public becouse the man is in law enforcement he is a sergeant but what about all the other cases with ordanary citizens they have to live with it and just cry it out or just shut up im sure if it was an avarege Joe they would have disconnected him already long time ago. This buitifull great country of ours needs an overhaul we need a big change both main political powers are good for the waste basket. Yet we pay so much for our medical insurance some of us never use in years but when we realy need it its like we never had coverege anyways so why do we pay so much every month i think get rid of all medical insurance and just pay half of what we pay now for private madical in our taxes just for medical covrege i think it would be about the same but would at least pay less. Now that the goverment is in the health insurance buisness i wonder how greaty they are also.
Insurance hater says
Insurance companies are such crooks, i hope they lose and this man and his family get thier just due… Im currently stage four cancer lymphoma going on my 6th chemo treatment my insurance they have contested each chemo as necessary.. Now theres been a growth found in my heart which has been labeled as a needed stat procedure insurance has played hard to comply for two months now, im slowly deteriorating as my family watches… Insurance companies are the biggest scam in America hmo,s are a joke.