A federal class-action lawsuit was filed June 4 against Oscar Health Insurance, alleging that the company required policyholders to pay deductibles and coinsurance for diagnostic breast imaging in violation of Texas law.
The suit, filed in United States District Court for the Southern District of Texas, Houston Division, alleges that Oscar Health Insurance continued to charge policyholders for part or all of the costs associated with diagnostic breast imaging after an update to Texas law that required insurers to pay 100% of the cost of breast-related diagnostic imaging under all non-Employee Retirement Income Security Act (ERISA) medical insurance policies issued or renewed in Texas on or after January 1, 2022.
Furthermore, the lawsuit alleges that while Oscar’s written policies are partly in compliance with the updated Texas law and the Affordable Care Act (ACA) by providing coverage for mammogram screenings for women 35 and older at no cost, the provider has failed to fully comply with the updated statute.
In a statement, law firms Jeeves Mandel Law Group, P.C. and Milberg Coleman Bryson Phillips Grossman PLLC, representing the plaintiffs in the suit, wrote that excluding interest, the amount in controversy exceeds $5 million, with the potential to reach $30 million considering statutory penalties, attorneys' fees, and additional costs.
According to the filing, Oscar “has required its insureds to pay 25% coinsurance after deductible, meaning that the insured pays the full amount until their deductible is met (which can be hundreds or thousands of dollars), and 25% of the cost thereafter (which likewise can be hundreds or thousands of dollars)”; the firms noted that there may be thousands of woman affected by Oscar’s actions.
Lauren Moody is the named plaintiff who brought the suit on behalf of herself and other affected Oscar policyholders.
In 2023, Moody underwent diagnostic breast imaging via ultrasound, which her doctor had ordered to evaluate a previously discovered abnormality. The MRI company charged $578 for the ultrasound.
Oscar allowed $161.22 of the charge and said that Moody was responsible for 100% of that amount toward her deductible. Moody appealed Oscar's decision, citing Texas law requiring Oscar to pay 100% of the cost; Oscar turned down the appeal.
