Anthem, Inc. Denial of Insurance Coverage for Lipedema
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Gianelli & Morris Sues Anthem, Inc. over Denial of Insurance Coverage for Lipedema

On January 17, 2019, Gianelli & Morris, a Los Angeles insurance bad faith law firm, filed a complaint against Anthem, Inc. and its utilization management arm Anthem UM on behalf of Robin Goolsby, a patient diagnosed with Stage 3 advanced lipedema whose request for coverage for tumescent liposuction was denied. Anthem UM’s denial letter stated that this type of surgery was not approvable because it was used to improve appearance but not improve health. Coverage for the surgery was denied as cosmetic. Ms. Goolsby appealed the decision but was again turned down, after which time she paid out-of-pocket for the surgery to relieve the effects of her progressive and debilitating lipedema.

This class action lawsuit seeks benefits, a determination of rights, and remedy for breach of fiduciary duty under the Employment Retirement Security Act of 1974 (ERISA) for Anthem’s refusal to cover claims for surgical treatment of lipedema.

Lipedema is a painful disorder “characterized by symmetric enlargement of the legs due to deposits of fat beneath the skin,” according to the National Institue of Health. Lipedema is a common condition that occurs almost exclusively in women, affecting up to 11% of women. Lipedema is a progressive disease that gradually worsens and expands to afflict not only the legs but also the upper extremities and other portions of the body in some cases. The NIH recognizes surgery as the only technique to remove abnormal fat tissue and cautions that such surgery should only be undertaken by surgeons with expertise in treating lipedema.

The plaintiff in the complaint was a member of an employer-sponsored health plan governed by the federal law known as ERISA, and seeks class certification of “All persons covered under ERISA health plans, self-funded or fully insured, that are administered by Anthem and whose claims for liposuction treatment of their lipedema were denied as cosmetic.” The complaint seeks to enforce and clarify rights to benefits under the plan, including payment of medical expenses.

The complaint also alleges that Anthem is an ERISA fiduciary which breached its fiduciary duty regarding administration and claims decisions under Anthem plans. The lawsuit seeks injunctions and orders requiring Anthem to reevaluate and reprocess the claims of the plaintiff and class members, and also to disgorge any profits Anthem accumulated due to improperly denied claims.

If you believe your case has been wrongfully handled by your insurance company and they may have acted in bad faith, review your options with the Los Angeles insurance attorneys at Gianelli & Morris to request a consultation.

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