Lawsuit by Policyholders Targets Anthem

Original story posted on: February 13, 2019

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Individual policyholders in Georgia launch a class-action lawsuit against Anthem for deceptive sales.

Early last week, Frances Kirby and John David Marks, two individual policyholders from Cook County, Georgia, filed a class-action lawsuit in federal court in Atlanta against Anthem and Blue Cross Blue Shield of Georgia for allegedly misleading them and thousands of other similarly situated consumers in the sale of Anthem’s Pathway health insurance plans.

Pathway is a product available through a Patient Protection and Affordable Care Act Health Care Exchange for consumers seeking individual and family health insurance policies. The gravamen of the complaint is that during the most recent open enrolment period, from Nov. 1 to Dec. 15, 2018, Anthem allegedly fraudulently induced Georgia consumers to buy Anthem’s individual health coverage by falsely representing that WellStar Health System, Inc., Georgia’s largest healthcare provider, was an in-network covered provider – when in fact, Anthem allegedly had notified WellStar several months earlier, in August 2018, that WellStar services would no longer be covered by the Pathway plan. 

The complaint alleges the following as ranking among the deceptive business practices in which Anthem engaged:

  • Throughout the enrollment period, the “provider finder” tool on Anthem’s website included WellStar doctors and hospitals as in-network providers, despite the company knowing they would not be in-network after Feb. 4, 2019, one month after the new policy was issued;
  • To enroll for Anthem’s Pathway individual insurance plan, new policyholders were required to select a primary care physician (PCP), and WellStar doctors were included among the list of qualifying PCPs policyholders could choose; and
  • In some instances, Anthem issued health insurance cards to plaintiffs that included the name of a WellStar doctor on the card, while failing to inform consumers that the coverage would be terminated and those PCPs would no longer be in-network on Feb. 4, 2019. 

The plaintiffs appear to take particular umbrage at the contention that Anthem never communicated clearly about the fact that the WellStar contract would be canceled one month into the new policy period, meaning WellStar providers would no longer be available. Instead, the complaint alleges, policyholders had to learn this news from their WellStar providers and/or the public statement WellStar issued indicating that WellStar services no longer were being covered by Anthem/Blue Cross Blue Shield’s Pathway plan.  

If the allegations are proved, the consequences for individual consumers could be significant. According to the complaint, the two named plaintiffs both have significant health issues, requiring them to be seen regularly by their WellStar PCPs and a large number of WellStar specialists. The plaintiffs allege they only chose Anthem over their previous health insurer after confirming that their WellStar primary care physicians and specialists and WellStar hospital were represented as in-network. They will experience a lapse in treatment as they seek to secure other in-network providers (from a provider list that is sparse due to the elimination of the WellCare providers) and will have to travel 25 miles to the next-closest covered hospital, the complaint alleges.

Since the open enrollment period is now closed, the plaintiffs also allege that consumers are locked into their Pathway plans under November 2019 and will continue to pay premiums for a health insurance product with fewer providers and hospitals, which many would not have purchased had they known the truth: that WellStar would not be in-network. 

Since the case was only filed last week, we have not had an opportunity to hear Anthem’s response to the allegations. Last week, Anthem announced that it was extending benefits regarding WellStar PCPs for another 90 days, until May 4, 2019. Media outlets such as Becker’s Hospital Review and the Atlanta Journal-Constitution are reporting that this change came at the prodding of the Georgia Department of Insurance, which governs whether health insurers are meeting legal standards with their policy offerings. 

We will continue to monitor this case as it develops, including as the defendants respond and the plaintiffs move the court to get a Georgia class certified.  


Mary Inman, Esq.

Mary Inman is a partner in the London office of Constantine Cannon, where she specializes in representing whistleblowers from the United States, Europe, and around the world under the various American whistleblower reward programs, including the False Claims Acts and the SEC, CFTC, IRS, and DOT whistleblower programs. Mary is a member of the RACmonitor editorial board and makes frequent appearances on Monitor Monday.

This email address is being protected from spambots. You need JavaScript enabled to view it.

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