Lawsuit Charges Kaiser Foundation Health Plan with Unfairly Denying Coverage to Treat Lipedema
On May 16th, the California insurance law firm Gianelli & Morris filed a complaint in the Superior Court of Los Angeles County in the case of Elena Valencia, et al. v. Kaiser Foundation Health, Plan, Inc., Case No. 19STCV17131. The lawsuit alleges that Kaiser breached its contractual duties and acted in bad faith by refusing to provide coverage for surgical treatment of the plaintiff’s lipedema. The lawsuit seeks general, special and consequential damages as well as an award of attorney fees and costs and punitive (exemplary) damages.
What is lipedema?
The National Institutes of Health (NIH) describes lipedema as a “disorder characterized by symmetric enlargement of the legs due to deposits of fat beneath the skin.” The appearance of large, column-like legs as well as disproportionate hips, stomach and buttocks are characteristic features of the disorder. Also, as fat cells expand, they interfere with the pathways of lymphatic vessels. Pain and immobility are the major complaints associated with the disorder. According to the NIH, the condition appears “almost exclusively in women,” and up to 11% of women worldwide may be afflicted.
Allegations in the complaint – breach of contract and breach of implied covenant of good faith and fair dealing
As to each of the plaintiffs named in the lawsuit, the complaint alleges breach of contract and breach of the implied covenant of good faith and fair dealing regarding Kaiser’s refusal to provide the requested coverage for treatment of the plaintiffs’ lipedema. According to papers filed with the court, Kaiser denied the requested surgical treatment, a specialized form of liposuction, as cosmetic and/or experimental. The complaint counters that Kaiser’s refusal to cover the treatment was done for purely financial reasons, claiming Kaiser doesn’t have physicians with the necessary expertise to diagnose and treat the disease so it improperly denies treatment rather than spend money on resources to bring patients relief.
Lawsuit alleges surgical treatment of lipedema is not cosmetic surgery
A reason given by Kaiser for denying the specialized liposuction to treat the plaintiffs’ lipedema is that it is “cosmetic” surgery. “Cosmetic surgery” is defined under California Health & Safety Code section 1367.63 as “surgery that is performed to alter or reshape normal structures of the body in order to improve appearance.” The same section of law defines “reconstructive surgery” as “surgery performed to correct or repair abnormal structures of the body caused by…developmental abnormalities… or disease to improve function [or] to create a normal appearance, to the extent possible.” Plaintiffs believe the treatment sought falls squarely within California’s reconstructive surgery law which mandates coverage in this situation.
Lawsuit alleges surgical treatment of lipedema is not experimental surgery
The complaint alleges that although Kaiser also bases its denial of specialized liposuction for lipedema treatment as an “experimental” surgery, this form of treatment is not only safe and effective but is also the only known treatment for the pain and immobility that result from lipedema. The lawsuit points out that specialized liposuction has been shown to be beneficial in various studies and is routinely performed at Stanford University Medical Center and other leading medical facilities.
As alleged in the complaint, lipedema is often misdiagnosed as obesity or lymphedema, but Kaiser has neither adopted appropriate guidelines for lipedema, trained physicians to diagnose and treat this debilitating condition, nor hired physicians with the requisite expertise to diagnose and treat lipedema.
The law firm of Gianelli & Morris successfully represented plaintiffs in the Gallimore case and currently has several cases pending in state and federal court on lipedema coverage denials. These cases include Christina Herzoff; Olivia Herzoff v. Anthem Blue Cross Life and Health Insurance Company 19STCV06260 and Jessica Manuel v. Blue Cross of California dba Anthem Blue Cross BC 721828 in the Los Angeles County Superior Court, as well as class action complaints in the United States District Court for the Central District of California (Robin Goolsby v. Anthem Inc. 2:19-cv-00392) and the U.S. District Court, Northern District of California (Michala Kazda v. Aetna Life Insurance Company 4:19-cv-02512-KAW).