Blue Cross of Idaho is fighting one federal lawsuit and recently lost a second after denying medical coverage to two men who the insurer claims were injured while committing illegal acts, reports Idaho Statesman.
Idaho law allows health insurers to refuse medical payments for members in certain situations, like if someone is hurt while committing a felony, intoxicated or taking unprescribed narcotics.
But two injured policyholders and an Idaho physicians group claim Blue Cross of Idaho is exploiting the "illegal activity" loophole as a way to deny payment and cut costs. State authorities never charged the injured policyholders with any crimes.
Because an insurer has a financial interest in finding legal wrongdoing, a third party should decide if a crime occurred, Susie Pouliot, CEO of the Idaho Medical Association, told Idaho Statesman.
"An insurance company [should not] be the judge, jury and executioner," Ms. Pouliot said.
Blue Cross of Idaho declined Idaho Statesman's request for comment. Vice President of Marketing Don Mann sent the following statement:
"Blue Cross of Idaho complies with all [patient privacy] requirements and does not release protected health information, and our healthcare policies comply with Idaho law ... which states: 'Intoxicants and Narcotics: The insurer shall not be liable for any loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of any narcotic unless administered on the advice of a physician.'"