Recording seems to refute claims made by Anthem

An Anthem Blue Cross representative works in a booth at the East Los Angeles Health Fair held at David Wark Griffith Middle School last September. (Gary Friedman / Los Angeles Times / September 21, 2013)

We've all heard stories about health insurance companies refusing to budge after denying a claim, often asserting that the policyholder was in the wrong.

David Cienfuegos said his wife was told by Anthem Blue Cross that his doctor was part of the insurer's coverage network, but then was left with the tab for about $5,800 in medical costs after Anthem insisted that it never said any such thing.

In this case, though, Cienfuegos, 40, has a digital recording of the Anthem rep clearly saying his surgery would be covered.

And he's suing to hold the insurer accountable.

"It's shameful," Cienfuegos told me. "It's like they have a policy of denying claims without even looking at the facts."

He said his wife contacted Anthem on Sept. 10 to make sure that surgery for a condition known as varicoceles, which can cause infertility in men, was covered under the plan and that his doctor, Philip Werthman, was in Anthem's network.

Having received verbal assurances on both counts, Cienfuegos said, he underwent surgery at a Los Angeles clinic and submitted a claim to Anthem on Oct. 28.

The company denied full coverage for the claim on Dec. 2, he said, ruling that Dr. Werthman was not part of Anthem's network. Any reimbursement Cienfuegos received thus would be at a lower out-of-network rate.

Cienfuegos appealed the decision, saying he and his wife had been assured by an Anthem rep that the doctor was indeed in-network. The couple included with their appeal a compact disc of the recording they'd made of the original exchange.

"Anthem says it can record calls for quality-assurance purposes," Cienfuegos explained. "So we did the same."

But on Feb. 19, Anthem once again denied full coverage of the claim, insisting that Cienfuegos was never told that his doctor was in-network or that his operation would be covered.

This was an intriguing position for the insurer to stake out, considering that the recording Cienfuegos had submitted appeared to contradict it on both points.

Cienfuegos' lawyer, William M. Shernoff, shared the recording with me. Cienfuegos' wife can be heard speaking at length with an Anthem rep who identifies himself as Howard.

Here's a portion of their conversation, which is also included in the lawsuit:

Wife: So how can I find out if the doctor we're working with is contracting with Anthem?

Howard: If you know the doctor's name, I can look them up for you.

Wife: The doctor who is doing the procedure … is Dr. Werthman, W-e-r-t-h-m-a-n.

Howard: Philip?… Yes, that doctor is in-network.

Wife: Oh, OK. So when I submit my claim form, that goes towards the in-network deductible?

Howard: Correct.... That is correct.

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