Breast surgery center and hospital claim Humana failed to pay for reconstruction

Andrea Dearden Oct. 27, 2010, 2:55am


A New Orleans surgery center and hospital are suing an insurance provider which they claim failed to pay for breast restoration procedures for cancer patients.

The Center for Restorative Breast Surgery LLC and St. Charles Surgical Hospital filed a lawsuit against Humana Health Benefit Plan of Louisiana Inc. and Humana Health Plan Inc. on Oct. 18 in Orleans Parish District Court.

According to the lawsuit, the Center for Restorative Breast Surgery provided breast reconstruction surgery to several breast cancer patients. St. Charles Hospital provided medical services to those same patients, the suit states.

The Center claims that, prior to performing the surgeries, staff contacted Humana Health Plan and asked for a verification of reimbursement for medical procedures.

The Center says it received that verification from Humana in an "arms length transaction" and says both parties were aware of the reimbursement rates. The Center claims this verification of benefits created a contract and a promise of payment between the Center and Humana.

However, when the Center billed the insurance company for reimbursement Humana allegedly paid an amount that was substantially less than the previously agreed-upon rate. The Center says numerous appeals to Humana have gone nowhere or have been denied without proper explanation. Other times the insurance carrier deemed the surgeries to be for "cosmetic" rather than medical reasons.

The Center for Restorative Breast Surgery is suing for breach of contract is asking for more than $2.7 million in unpaid claims plus interest. St. Charles Hospital is asking for more than $120,000 plus interest.

Jacqueline G. Griffith of Metairie is the attorney representing both the Center for Restorative Breast Surgery and St. Charles Hospital.

Orleans Parish District Court Case No. 10-10649

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