Class action suit against Anthem over dispute with WellStar adds new plaintiffs, new allegation

A class action lawsuit filed against Anthem Blue Cross Blue Shield over its dispute with WellStar Health System last month is expanding, adding new plaintiffs and a new allegation against the insurance company.

The suit, filed by Marietta attorney Jason Doss in federal court on Feb. 5, originally named two Cobb County residents as plaintiffs and includes in the class anyone who purchased Anthem’s Pathways health insurance plan, which is sold on the individual health insurance exchange created by the Affordable Care Act.

The core of the complaint stems from a dispute over whether WellStar is considered “in network” for customers who purchased Anthem’s Pathways insurance plans. The plaintiffs claim that WellStar was listed as in network when they signed up for the Pathways plans during open enrollment in November and December 2018.

However, Anthem had already notified WellStar in August that it planned to drop the health system from its network effective Feb. 4, according to WellStar. That deadline came and went with no new agreement between WellStar and Anthem.

On Monday, Doss filed an amended version of the complaint that added five more plaintiffs and a new allegation against the insurer, claiming that Anthem has unilaterally changed the terms of their plans despite provisions in the insurance plans that would prevent them from doing so.

The lawsuit asks for more than $5 million in damages.

Additionally, in what could be a first under the Affordable Care Act, the lawsuit asks the federal court to grant the plaintiffs a “special enrollment period,” which would allow them to sign up for a new insurance plan. The ACA contains provisions that allow for a special enrollment plan if an insurer violates a provision of its contract with a customer, according to the lawsuit.

NEW ALLEGATION

According to the amended complaint, Anthem notified customers on or around Feb. 21 that if they needed to see a specialist, they would need a referral from their primary care doctor.

“Your 2019 Member Contract incorrectly said you don’t need a referral from your primary care doctor to see a specialist. Your plan does require a referral to see a specialist. That was our mistake, and we’re sorry for any confusion,” a copy of a letter one of the plaintiffs received states.

Doss included the letter as an attachment to the amended complaint.

When the plaintiffs signed up for insurance coverage through Anthem, they were provided with a contract that specified how that contract could be changed, the lawsuit alleges.

“No change in this contract is valid unless it is signed by the President of Anthem. … Anthem has the right to amend this contract at any time by giving you written notice of the amendment at least ninety days before the amendment takes effect. You must agree to the change in writing,” the lawsuit quotes the contract as saying.

However, the letter telling customers that they now needed referrals was not signed by the president of Anthem or agreed to in writing by the customers, the lawsuit claims. The letter is evidence of Anthem breaking the contract with its customers, the suit alleges.

“Anthem admits in this letter that it breached its contract with plaintiffs and class members,” Doss said in a statement. “Trying to change the rules after the fact and now force Pathways policyholders to get a referral from a primary care provider is a material breach of their contract. It also adds insult to injury given that Anthem misrepresented to consumers that these same WellStar primary care physicians were in-network when it knew that they were not.”

A spokesperson for Anthem told the MDJ in February that the insurance company does not comment on pending litigation. Calls and emails to that spokesperson — Christina Gaines, communications director, public relations — went unanswered on Monday.

As of Monday, the federal court docket did not show a response to the suit or any other document filed by attorneys representing Anthem.

NEW PLAINTIFFS

One of the five new plaintiffs who have signed on to the lawsuit is 27-year-old Audrey Logan. According to the suit, Logan was diagnosed with a heart condition known as CPVT, which can lead to abnormal heart rhythms, in May 2008. She was then diagnosed with another heart condition, cardiomyopathy, in July 2018.

Her cardiologists, both of whom work for WellStar, told her in July 2018 that she would need a heart transplant if medication she was taking was not effective, according to the lawsuit. By the fall of 2018, her doctors told her the medication was not working and she would need a transplant.

Around that same time, Logan was looking for a new insurance plan during the 2018 open enrollment period and picked the Anthem Silver Pathways Guided Access HMO plan, according to the lawsuit.

Then, in February, Logan learned WellStar and her cardiologists were not in network for the plan, according to the suit. Furthermore, she learned that Emory Healthcare, the only health care provider in Georgia that performs heart transplants, also does not accept her Pathway health insurance plan “even though Anthem’s website represents that Emory is in-network,” according to the suit.

Another new plaintiff in the suit is 28-year-old Ashley Waldman, who is currently seven months pregnant and expecting a girl in May, according to the suit. She signed up for an Anthem Bronze Pathway Guided Access HMO plan during open enrollment last year.

Waldman’s OB-GYN only has hospital privileges at WellStar Kennestone Hospital, the lawsuit states. and while her doctor is still considered in-network under her insurance plan, Kennestone is not.

Because her doctor only has hospital privileges with WellStar, “she now must search for a new medical specialist during the last trimester of her pregnancy and a change in her treating physician will undoubtedly cause a lapse in her medical treatment while she conducts a search for in-network providers that she is comfortable with and who are taking new patients,” the suit states.

The other new plaintiffs are Wanda Silva, Tonya Beach and David Frohman, who join original plaintiffs Frances Kirby and John David Marks.