Overview
Cohen Milstein is serving as co-counsel for former Wake Forest and NBA professional basketball star Rodney Rogers, in a managed care abuse lawsuit against Blue Cross and Blue Shield of North Carolina (BCBSNC) for breach of contract, unfair and deceptive trade practices, and bad faith.
Since suffering a spinal cord injury in 2008, which permanently rendered Mr. Rogers a quadriplegic, he has been insured under BCBSNC health insurance policies. On December 22, 2022, BCBSNC terminated coverage for his in-home nursing care, which is an essential part of his specialized and medically necessary in-home medical care coverage.
The complaint, filed on February 12, 2024, in the Superior Court of Durham County, North Carolina, alleges that BCBSNC’s denials of care for Mr. Rogers are not based upon qualified medical opinion and sound medical evidence, but rather on its own, self-serving pecuniary interests and its self-authored “Corporate Medical Policies.”
Background
In 2008, Mr. Rogers was involved in a dirt bike crash in rural Vance County north of Raleigh, North Carolina. He suffered a spinal cord injury, permanently rendering him a quadriplegic. Due to his injury, he is dependent on a ventilator, relies on a gastric tube for his sustenance and to receive medication, and requires specialized in-home medical care.
Since approximately 2014, Mr. Rogers has been insured under a health insurance policy by BCBSNC. The policy provides that BCBSNC will cover or reimburse “members” and/or other eligible beneficiaries for medically necessary care or treatment. Under the terms of this policy, BCBSNC had continuously covered Mr. Rogers’ in-home nursing care.
In October 2022, Mr. Rogers underwent multiple hospitalizations and surgeries to repair a perforation of his stomach and for drain placement to treat pelvic abscesses. Following surgical debridement in December 2022, his medical providers sought renewed authorization of Mr. Rogers’ in-home nursing care. On December 22, 2022, BCBSNC denied coverage for nursing care, alleging for the first time that the care requested “does not meet the definition of Medical Necessity found in the member’s benefit booklet.”
After BCBSNC’s initial denial, Mr. Rogers provided BCBSNC with letters from six of his treating physicians detailing the complexity of his medical needs and confirming the medical necessity of continued in-home nursing care. Despite the appeals of Mr. Rogers’ physicians, BCBSNC reaffirmed its denial for the in-home nursing care that it had for years covered.
On February 24, 2023, Mr. Rogers was admitted to the intensive care unit at Duke University Hospital to be treated for septic shock, metabolic acidosis, hyponatremia, acute kidney injury, urinary tract infection, and cardiac tamponade requiring pericardiocentesis. Mr. Rogers’ provider submitted a new claim for preauthorization of ongoing private duty nursing services. BCBSNC denied the claim, stating “In this case, while the member’s needs are complex, it appears that the member’s condition is stable, the caregivers have been trained, the care does not require a skilled nurse, and the member does not meet policy criteria for coverage.”
Since BCBSNC first covered Mr. Rogers’ in-home nursing care services, he has experienced no overall improvement in his medical condition to justify a determination that in-home nursing care is no longer medically necessary.
Mr. Rogers is represented by Charles McB. Sasser and Rachel C. Matesic of The Sasser Law Firm, P.A., who filed the complaint on February 12, 2024, and Theodore J. Leopold of Cohen Milstein Sellers & Toll PLLC.