The American Dental Association (ADA) said today it
is suing one of the nation's largest health care companies, WellPoint Health Networks Inc., and its wholly owned subsidiary, Blue Cross of California, charging the health care conglomerate with breach of contract, unlawfully interfering with the dentist-patient relationship and trade libel.
The class-action lawsuit, filed here in U.S. District Court for the Northern District of Illinois on behalf of the ADA and its members, seeks relief under the Employee Retirement Income Security Act (ERISA) for breach of contract, and under supporting state laws for tortious interference and trade libel. Three practicing dentists joined the ADA in the suit.
"By regularly providing false information that casts doubt on dentists' reputations and disparages the value of dental services, WellPoint has seriously undermined the trust between dentists and their patients," said Dr. Gregory Chadwick, ADA president. "We suspect there are instances in which patients have even elected to forego treatment altogether."
The plaintiffs charge WellPoint, one of the largest providers of dental coverage with more than 2.6 million dental-plan members, with regularly breaching its contract with members by failing to pay non-plan providers' actual charges for professional services rendered.
According to the complaint, WellPoint's contract states that the insurer will pay out-of-network providers' actual charges unless it has appropriate data to substantiate a lower payment. The lawsuit claims that WellPoint did not pay those charges and failed to substantiate the lower payments, because it based them on flawed "usual, customary and reasonable" (UCR) data for the
lower amounts paid to out-of-network dentists. The plaintiffs further claim that the company knew or had reason to know the lower amounts it paid were below proper UCR amounts.
The lawsuit also charges that the language on WellPoint's Explanation of Benefits (EOB) form, telling the patients of out-of-network dental providers that it would not pay the dentists' actual charges because these dentists charges are "not customary and reasonable" is misleading, has caused dentists to lose patients and constitutes trade libel.
This is the second class-action complaint filed by the ADA in less than one year against a major dental plan insurer. In August, the association filed a similar suit against Aetna, the nation's third largest provider of dental coverage.
"We are putting insurers on notice not to interfere with the doctor-patient relationship because we no longer will tolerate such unwarranted interference," declared Dr. Chadwick.
The plaintiffs seek an injunction to prohibit WellPoint from continuing to engage in the allegedly unlawful business practices, as well as compensatory and punitive damages.
The not-for-profit ADA is the nation's oldest national dental association, representing more than 142,000 members. It advocates for public health and promotes the art and science of dentistry. ADA member dentists have a commitment to provide high-quality oral health care and promote accessible oral health care to everyone.
The complaint is available online at www.ada.org
