Facts

Dr. Steven Villalobos was employed as a Physician Advisor with Alignment Health Plan. The Plan, which also provided Dr. Villalobos' medical benefits and coverage, was funded by a group insurance policy issued by Blue Shield of California. The policy required insureds, such as Dr. Villalobos, to select a primary care physician from a network of authorized providers. Dr. Villalobos' assigned primary care physician was HealthCare Partners Medical Group.

In June 2019, when Dr. Villalobos suffered from a serious infection near his toes, he received a referral to be treated at the Inter-Community Medical Center where he was admitted, treated with antibiotics and his wound cleaned and debrided. When the debridements proved unsuccessful and his infection continued to worsen, Dr. Villalobos consulted with the general surgeon and vascular surgeon assigned to his case, who told him his only option was amputation. Dr. Villalobos then asked HealthCare to be transferred to another facility, preferably one specialized in limb salvage. HealthCare denied the request, instead choosing a network orthopaedic foot surgeon from another hospital who concurred with the two surgeons, recommending amputation. Dr. Villalobos decided to call the Ronald Reagan UCLA Medical Center and was told it had contracts with both HealthCare and Blue Shield. After going to UCLA's emergency room, Dr. Villalobos consulted with a podiatrist specializing in diabetic limb salvage, who stated that though he would have to do some slight amputation, they could save most of his right foot. When HealthCare refused to approve the UCLA treatment, Dr. Villalobos still chose to continue treatment with UCLA, and after recovery, was able to retain continued use of his foot.

After submitting the UCLA bills to Blue Shield, Blue Shield initially refused to pay, but eventually paid for some, leaving a substantial balance for Dr. Villalobos who appealed the denial. Dr. Villalobos sued Blue Shield in USDC Central.

PLAINTIFF'S CONTENTIONS: Plaintiff contended that under his policy and rules governing the Employee Retirement Income Security Act, defendant had an obligation to either provide adequate "in-network" treatment or refer it to a provider who could do so. Requiring amputation of an entire lower leg when all that was medically required was amputation of a single toe did not constitute adequate treatment.

DEFENDANT'S CONTENTIONS: Defendant denied plaintiff's contentions.

Result

The court entered judgment in plaintiff's favor in the amount of $89,920.91, along with any post-judgment interest.