LOS ANGELES (CBSLA.com) — The wife of an incapacitated sheriff’s sergeant is suing Anthem Blue Cross for denying him more than $1 million in hospital stay benefit coverage after he did not awaken from anesthesia following surgery.
The complaint was filed Tuesday in Los Angeles Superior Court by Melissa Williams on behalf of herself and as the guardian of her husband, Los Angeles County sheriff’s Sgt. Glen Williams. The suit, which seeks unspecified compensatory and punitive damages, alleges Anthem found that Williams’ hospital stay claim lacked medical necessity.
According to the lawsuit, Williams began working for the LASD in 1985 and was promoted to sergeant in 2011. He and his wife celebrate their 30th anniversary this year and have three children, all in their 20s.
Williams was 53 years old and was eating dinner with his family on New Year’s Day 2014 when the meat became lodged in his esophagus, according to the lawsuit. He underwent surgery the next day at Antelope Valley Hospital.
“Immediately before Glen underwent the procedure at Antelope Valley, he called Melissa to tell her he loved her,” the suit states. “But after being placed under anesthesia, Glen did not wake up and currently remains in an incapacitated state.”
Williams spent a month in intensive care at Antelope Valley Hospital before being transferred to Kindred Hospital for another three months, then was transferred in April 2014 to Providence Holy Cross Medical Center in Mission Hills, where he remains today, according to the lawsuit.
Four weeks after Williams arrived at Holy Cross, Blue Cross began denying benefits for his continued stay, the suit alleges.
Blue Cross approved Williams’ stay from Jan. 13 to Feb. 14, as well as Feb. 14 to March 16, but not for any other days after last June 23, according to the lawsuit.
Denying their claim makes the plaintiffs responsible for medical expenses through Dec. 3 in a sum of $1.05 million and have continued to incur daily expenses in the sum of approximately $6,500 since Dec. 3, with the exception of the random two-month period approved by Blue Cross without explanation, the suit states.
Melissa Williams was forced to apply for Medi-Cal benefits for her husband even though she continues to pay Blue Cross premiums and would rather not have assistance from taxpayers to pay his hospital bills, according to the lawsuit.
“In reaching the conclusion that Glen’s continued stay at Holy Cross was not medically necessary, Blue Cross relied on a clinical guideline for skilled nursing facility services which was not attached to or disclosed in the evidence of coverage,” the suit states. “By ignoring the definition of medical necessity in the evidence of coverage, and using a different definition undisclosed to plaintiffs, Blue Cross has breached the expressed and implied obligations it owed plaintiffs under California law.”
Since arriving at Holy Cross, Williams has breathed through the tracheostomy in his neck and received “aggressive tracheostomy care and suctioning at least every four hours,” the suit states. “He also receives regular breathing treatments on the same schedule.”
Williams suffers from deep vein thrombosis, in which blood clots form in one or more of his deep veins, and he is constantly monitored for pressure sores, the suit states. He is “at high risk” for pneumonia and urinary tract infections, the suit states.
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