5th Circuit reverses, says Blue Cross erred in Eunice case
The Fifth Circuit Court of Appeals this week ruled that Dr. Richard LaFleur of Eunice was entitled to benefits that Blue Cross refused to pay before he died in November 2005.
Before his death, LaFleur’s estate sued Blue Cross/Blue Shield of Louisiana, the state’s largest health insurer, for stopping payment for LaFleur’s treatment in 2003, two years after he went into a coma.
LaFleur was covered by a group health plan at The Family Health Clinic when he went into the coma during major surgery.
According to the case file, Blue Cross agreed to cover the cost of nursing home care for the comatose LaFleur.
But in 2003 Blue Cross physicians decided that his medical condition no longer met coverage reimbursement requirements, according to the court record. They did so without input from LaFleur’s attending physicians, the court noted.
Jacque Pucheu, Jr., on behalf of LaFleur, sued the insurer in 2004. The litigation seeking $200,000 in benefits from Blue Cross continued after LaFleur died.
In 2007, Western District Judge Tucker Melancon dismissed the suit.
On appeal, the circuit court ruled this week that Blue Cross failed to substantially comply with procedural requirements for determining the late doctor’s health benefits under the federal Employee Retirement Security Act.