This is a huge issue. You need a specialist and you have an HMO. But the HMO doesn’t have anyone with that specialty in their network in your area. In this case insurance companies are supposed to pay for you to go to an out-of-network specialists. But as with so many other issues, a health insurance company is going to fight tooth and nail before agreeing to pay for anything that costs money.

So this California court case caught my eye. In a tentative order issued today, the judge denies Blue Cross’s motion to dismiss a lawsuit by one of its members on just this issue.

Brittany Crawford had a Blue Cross HMO and required surgery for lipedema. No doctors in her HMO could perform this surgery. Under the insurance contract, Blue Cross was required to pay for an out-of-network surgeon in the event one could not be found in network. Ms. Crawford alleges Blue Cross refused to pay for an out-of-network surgeon, knowing there were no capable surgeons in-network. She filed a grievance, which (surprise, surprise) Blue Cross denied.

Ms. Crawford sued the insurer for breach of contract and “breach of the covenant of good faith and fair dealing” for failing to properly investigate and adjudicate the grievance. Blue Cross moved to dismiss the good faith and fair dealing claim. The judge denied their motion, holding that Ms. Crawford’s allegations would be sufficient, if true, to establish Blue Cross’s liability for violating the covenant of good faith and fair dealing.

Good for the judge! Ms. Crawford’s case is exactly the same as what so many of us go through. And now a California court says that fact pattern makes Blue Cross liable.

And more importantly, good for Ms. Crawford! She took on a huge corporation and she’s winning (so far). Of course this may get overturned on appeal, or more likely it will get settled soon. But for today, Ms. Crawford is my hero.

A copy of the tentative order can be found here: Tentative ruling in deparment 54: BRITTNEY CRAWFORD VS BLUE CROSS OF CALIFORNIA DBA ANTHEM BLUE CROSS AND DOES 1 THROUGH 20, INCLUSIVELY – 22STCV09453, Nov. 10, 2022 | Trellis