The state’s lawsuit claims insurance company wrongly rejected thousands of medical claims.
A lawsuit in Montana is moving forward against the state’s largest health insurance provider after a federal judge agreed the case could cover not just one family but potentially thousands of others. The case centers around how Montana Blue Cross-Blue Shield, a company under Health Care Service Corporation, handled high-dollar medical claims, often labeling them as not medically necessary. According to the court filings, many of these denials came without proper review or enough medical oversight, leaving patients with large bills or facing financial ruin.
The original lawsuit was brought by a couple from Helena. They challenged the insurance company’s denial of a claim related to serious back surgery. The federal judge ruled that the case could be expanded into a class-action lawsuit, meaning other people who had their claims denied in similar ways might also be included. The judge pointed out that the company didn’t offer much to challenge this request, and evidence showed a consistent pattern of denials without following Montana’s rules.
Attorneys involved say the company flagged any claim over $50,000 and followed a set process that skipped important steps. Reviewers often didn’t look at all available records or speak with the doctors who provided care. In some cases, the reviewers weren’t even specialists in the areas they were reviewing. One of the doctors who denied a claim admitted she had no background in spine conditions but still reviewed a case involving spinal surgery. Another employee said they were not allowed to ask for more records or speak with the patient or the treating doctor before making a decision.
Court records also show that reviews of these expensive claims were often rushed. One medical reviewer went through several files in a single day, spending only minutes on each one. The lack of detailed review meant that some claims were denied based on checklists or technicalities rather than full consideration of medical need.
Montana law requires insurance companies to make a real effort to look at all available information before saying no to a claim. The lawsuit says the company did not follow this rule and instead used a process that leaned heavily toward denial without enough review. Documents revealed during the case show that more than 15,000 claims were denied in Montana in the last five years for being labeled not medically necessary. About a quarter of those decisions were appealed, and roughly one-third of those appeals were reversed, meaning the original decision was wrong.
A former employee testified that many people simply pay the bills themselves when their claim is denied, even if they have insurance. The company eventually agreed to cover the claim for the Helena couple after the lawsuit was filed, but state law still allows them to seek additional damages, including for pain, suffering, or legal fees.
The case has drawn attention because it shows how a large insurance provider may have built a system where denying claims was routine. While not every denial was proven to be wrong, the pattern of behavior raised concerns that patients were not getting a fair review. The court will now allow the case to include others who might have been affected in the same way, creating the possibility of a much larger legal and financial outcome.
Sources:
Federal judge OKs class-action lawsuit against state’s largest insurance carrier
Judge Approves Class-Action Lawsuit Against Montana’s Largest Insurer
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