FORT LAUDERDALE – Florida-based BioMatrix Specialty Pharmacy LLC recently filed a lawsuit in U.S. District Court for the Southern District of Florida against Horizon Healthcare Services for allegedly discriminating and refusing to pay for hemophilia medications.
BioMatrix and other plaintiffs in the case are specialty pharmaceutical companies that provide critical specialty drugs to treat significant medical conditions, including hemophilia, according to the lawsuit filed July 20.
“Horizon has undertaken a discriminatory strategy to evade its financial obligations to its most vulnerable members by selectively refusing to pay for high-cost hemophilia medications and services, thereby depriving its members of the very medication they need to survive,” the lawsuit said.
According to the lawsuit, Horizon issued a small group health insurance policy – the Horizon Direct Access Plan – to an employer, Pacific Health Group LLC, for the plan benefit year Oct. 1, 2016 – Oct. 31, 2017.
“The plan explicitly provided its members with coverage for medically necessary medications and services for hemophilia, a rare and debilitating blood disease requiring constant care and treatment through specialty drugs that companies like the BioMatrix plaintiffs provide,” the lawsuit said.
The members expected that the benefits would be paid because Horizon collected and retained all of the premiums in exchange for such coverage at all times during the plan benefit year, according to the lawsuit.
Horizon arbitrarily denied the members’ highest cost claims for life-saving medications even though there was no legitimate dispute that such claims were for covered services, the lawsuit said.
“Horizon only targeted the medically necessary claims of the plan’s members who suffer from hemophilia,” the lawsuit stated.
According to the lawsuit, Horizon made a false statement by saying “it informed its members that the basis of the denials was that the ‘service is excluded from your benefit plan.’”
The members timely appealed Horizon’s denials in April 2018, but Horizon never responded to the individual member appeals, according to the lawsuit.
“Rather, it sent a single letter from its special Investigations unit’s chief investigator, Scott Johnson, to Pacific Health Group, the members’ employer, asserting without any supporting evidence or documentation that Pacific Health Group was not a valid small group,” the lawsuit stated.
Horizon ignored the legal protections afforded its members under the Employee Retirement Income Security Act of 1974, the lawsuit said.
Horizon’s actions violate the mandates of the Affordable Care Act, which includes specific provisions ensuring that small groups can obtain affordable coverage notwithstanding the medical history of the beneficiary population, according to the lawsuit.
“Under these provisions, it is flatly illegal for insurance companies like Horizon to target and discriminate against individuals suffering from debilitating conditions such as hemophilia as it has done here,” the lawsuit said.
According to the lawsuit, Horizon has failed to pay at least $45 million in billed charges to the BioMatrix plaintiffs.
The plaintiffs are requesting a jury trial and are asking the court to declare that Horizon violated the terms of the plan, breached its fiduciary duty to the plaintiffs and failed to comply with ERISA’s timely claims procedure regulation, the Affordable Care Act’s non-discrimination provision and the Americans with Disabilities Act.