California Insurance Law Firm Sues Anthem, Inc. over Denial of…

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.

Gianelli & Morris announces that on January 17, 2019, attorneys Robert S. Gianelli, Joshua S. Davis and Adrian J. Barrio of Gianelli & Morris in Los Angeles filed a complaint in the United States District Court for the Central District of California. The case is Robin Goolsby v. Anthem, Inc. and Anthem UM Services, Inc., Case No. 2:19-cv-00392. This class action complaints 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.

According to the National Institutes of Health, lipedema is a painful disorder “characterized by symmetric enlargement of the legs due to deposits of fat beneath the skin.” The NIH categorizes lipedema as a common condition that occurs almost exclusively in women and affects up to 11% of women. According to NIH, 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 complaint alleges that a surgical procedure known as tumescent liposuction is the only effective treatment for the pain and immobility caused by lipedema. Tumescent liposuction is a procedure that allows large volumes of subcutaneous fat to be removed after injecting the site with a solution containing epinephrine and lidocaine.

Gianelli & Morris filed the complaint against Anthem 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.

Complaint filed as Class Action

The plaintiff in the complaint was a member of an employer-sponsored health plan governed by the federal law known as ERISA, found at 29 U.S.C. 1001 et seq. The complaint 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.

About Gianelli & Morris

Gianelli & Morris is a California insurance law firm representing policyholders who have had their claim for coverage or benefits denied or have otherwise been treated unfairly by their insurance company.

Contact Information

Carter Spohn
Gianelli & Morris
550 South Hope Street, Suite 1645, Los Angeles, CA 90071
213-489-1600
https://www.gmlawyers.com/

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