Anthem, Inc. and Anthem UM Services, Inc. Undisclosed Settlement

In a significant development, Anthem, Inc. and Anthem UM Services, Inc., collectively referred to as Anthem, have reached a settlement in a class-action lawsuit. The lawsuit, Atzin v Anthem, centered around allegations that Anthem used erroneous criteria to deny requests for microprocessor-controlled knee and foot-ankle prostheses as not medically necessary. The settlement aims to provide relief to class members who had their requests denied and paid out-of-pocket for the prostheses.

Detailed analysis of the settlement

The settlement in the Atzin v Anthem case is a significant development for individuals who had their requests for microprocessor-controlled knee and foot-ankle prostheses denied by Anthem. The lawsuit alleged that Anthem used improper criteria to deny these requests, deeming them not medically necessary. The exact settlement amount has not been disclosed on the official settlement website.

The settlement aims to provide relief to class members who had their requests denied and paid out-of-pocket for the prostheses. The reimbursement will be subject to a reduction only for the cost-share the class member would have paid under their health plan with Anthem if the claim had been initially approved as an in-network service.

Important Dates

The court held a fairness hearing on August 29, 2022, to determine whether to approve the settlement. After the hearing, the court decided on the approval and the amount of fees and expenses for Class Counsel and the Class Representatives. The exact claim deadline has not been provided on the official settlement website.

Who are the Class Members?

Class members eligible for benefits under the settlement include individuals covered under Anthem plans governed by ERISA, self-funded or fully insured, who had their requests for microprocessor-controlled knee or foot-ankle prostheses denied during the applicable statute of limitations period. The denial must have been based on Anthem's Former Medical Policy on Microprocessor Controlled Lower Limb Prosthesis or the Revised Former Medical Policy (Knee Change) on Microprocessor Controlled Lower Limb Prosthesis.

There are two tiers of class members:

• Those whose request(s) for microprocessor-controlled knee prostheses were denied.
• Those whose request(s) for microprocessor-controlled foot-ankle prostheses were denied.
  

Class members who exclude themselves from the settlement will not be able to seek coverage or reimbursement for expenses incurred for a prior microprocessor-controlled knee or foot-ankle prosthesis through the settlement.

What Can Class Members Claim?

Class members who paid out-of-pocket for a microprocessor-controlled knee or foot-ankle prosthesis and had a post-service claim or pre-authorization request denied by Anthem during the relevant time period can make a claim for reimbursement. The reimbursement will be subject to a reduction only for the cost-share the class member would have paid under the terms of their health plan with Anthem if the claim had been initially approved as an in-network service.

The exact amount of the reimbursement will depend on the individual's out-of-pocket expenses and the terms of their health plan with Anthem. It is important for class members to carefully review the terms of the settlement and their health plan to understand what they may be eligible to claim.

Is Proof Required to Claim the Reward?

Yes, class members need to provide proof of payment for the microprocessor-controlled knee or foot-ankle prosthesis and documentation of the denial by Anthem. The proof will be used to verify the claim and determine the amount of the reimbursement.

Why is there a class action settlement?

The class action settlement is the result of allegations that Anthem used erroneous criteria to deny requests for microprocessor-controlled knee and foot-ankle prostheses as not medically necessary. The settlement provides a resolution to these allegations and offers a way for affected individuals to seek reimbursement for out-of-pocket expenses incurred for these prostheses.

After the fairness hearing held on August 29, 2022, the court decided on the approval of the settlement and the amount of fees and expenses for Class Counsel and the Class Representatives. The next step for eligible class members is to submit a claim for reimbursement by providing the necessary proof of payment and documentation of denial by Anthem.