Brief introduction to the case: Doe (name changed) vs. Blue Cross of California

(Summarized below by Larry Weisenthal, witness for the Plaintiff)

SUPERIOR COURT OF THE STATE OF CALIFORNIA
COUNTY OF SAN DIEGO, NORTH COUNTY DIVISION
CASE NO: SN013292
SUPERIOR COURT JUDGE HON. YURI HOFMANN

Oral Arguments presented April 12, 2002; Follow-up written arguments April 25, 2002 and May 9, 2002; Judgment June 3, 2002

Ms. Doe's position is that she paid her insurance premiums and is entitled to coverage for medical expenses required for the management of her breast cancer. She was faced with the daunting challenge of a disease with a known 5 year survival rate of only 10%. There were a variety of chemotherapy choices and she wanted to receive the treatment most likely to work. Two different board certified medical oncologists experienced in managing cancer patients on the basis of information provided by our assays determined that the information provided by our testing would be of help in selecting the treatment most likely to work. This testing was, therefore, ordered and performed on two separate occasions (February 24, 1998 and June 16, 2000).

On each occasion, there is both sworn testimony and written documentation that the results of the testing did, indeed, influence directly the choice of treatment to be used. WellPoint Blue Cross did, indeed, pay for the cost of the treatments (one of which, at the time, would have been considered to be somewhat unconventional if by no means unreasonable, but which would not have been given absent performance of our testing services). However, WellPoint Blue Cross did not pay for the laboratory testing, itself, on the basis of the fact that the tests did not meet the internal coverage guidelines of WellPoint Blue Cross. Ms. Doe (who has continued to do quite well on assay-directed treatment 5 years following her diagnosis, thus doing much better than the average patient faced with this most aggressive and feared form of breast cancer) has been forced to pay for the tests herself and believes that WellPoint Blue Cross was wrong to deny coverage.

WellPoint Blue Cross's position was clearly spelled out by their representative, Mr. Christopher Loftin, if very ambiguously defended in the pre-trial letters to Ms. Doe authored by various WellPoint Blue Cross-employed physicians.

Mr. Loftin stated that WellPoint Blue Cross determines its own coverage policies, despite whatever opinions I or others may have. The patient agreed to those coverage policies in accepting the contract provisions of her policy and, thus, is not entitled to payment for what WellPoint Blue Cross has determined is a non-covered service. Furthermore, WellPoint Blue Cross maintained that, in the event a judgement for Ms. Doe was rendered, the total amount of the award should only have been for $550, which WellPoint Blue Cross says is all that would be paid for this type of service provided by a non-participating ("out of network") provider, such as myself.

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