This is GREAT NEWS for all of those Patients who are denied coverage for Proton Therapy even though they have this treatment in their policies. (Johns doctor had to go back and forth with our insurance carrier and prove that Proton Therapy had to be done as it was better for him than radiation or surgery.) In the end they agreed with our doctor and allowed the treatment. This should not be an issue IF a doctor says it is necessary for any patient IF it is covered in their policy. I always wondered how an insurance company can decide which is best for you.
Some important facts to review if you are denied coverage ~ Top 10 Myths about Proton Therapy for Prostate Cancer.
You may be surprised to learn what the insurance carriers don't seem to know especially when they tell your doctor it is experimental.
Here are the top 3:
Proton therapy was FDA approved for use in the U.S. in 1988—24 years ago
Berkeley Radiation Laboratory treated the first patient with protons in 1954.
Medicare and about 180 private insurers consider proton therapy an established technology, and have been reimbursing for proton therapy for more than 20 years.
Aetna Owes $26M Over Denied Cancer Treatment, Jury Says
Law360 (November 8, 2018, 6:33 PM EST)
An Oklahoma jury this week slammed Aetna with two verdicts totaling nearly $25.6 million, finding the insurer willfully acted in bad faith when it repeatedly refused to cover proton beam therapy recommended for a woman’s cancer. The Oklahoma City jury returned on Monday with a liability and compensatory damages verdict in favor of plaintiffs Ron Cunningham and the estate of his deceased wife, Orrana Cunningham, and on Tuesday found in their favor after a second-phase trial on punitive damages, according to the case docket.
The plaintiffs had alleged that Aetna Life Insurance Company had acted in bad faith in refusing to cover proton beam therapy — a type of targeted radiation treatment — recommended by the doctors treating Orrana Cunningham’s nasopharynx squamous carcinoma, a cancer located in the upper part of the throat near the base of the skull.
After deliberating for roughly three hours following a 12-day trial, the jury on Monday awarded $15 million to Orrana Cunningham’s estate and $500,000 to Ron Cunningham for emotional distress, and roughly $92,000 for their out-of-pocket spending on the cancer treatment, according to Cunningham attorney Doug Terry of Doug Terry Law. On Tuesday the jury awarded $10 million in punitive damages, according to Terry. The verdict forms were not available on the case docket as of Thursday.
“The people of Oklahoma county spoke loudly to send a message to the insurance industry that they’re not going to put up with insurance companies that recklessly disregard the rights of their policyholders, and we hope the verdict will help other people dealing with that in the future,” Terry told Law360 on Thursday.
Aetna had rejected coverage of the proton therapy — recommended because Orrana Cunningham’s cancer was so close to her brain — because the therapy was purportedly experimental, but that the evidence showed that the Aetna doctors who made those decisions spent less than an hour evaluating the case, Terry said.
“They were unqualified medically to be making these decisions, they were untrained in how to properly investigate and evaluate an insurance claim, they were overworked because they were handling way too many claims,” he said.
In a company statement, Aetna said its sympathies were with the Cunninghams, but that the public court record showed it had followed the proper procedures in the case. Aetna covered “proven safe and effective” radiation therapy, but the Cunninghams chose to instead pursue the proton beam therapy, for which there is a lack of clinical data, according to the statement.
Aetna’s denial was upheld through two levels of internal appeal, as well a review by an independent radiation oncologist — a review that was not permitted to be used at trial, according to the statement.
Aetna’s statement said it had no comment on “juror motives” or a potential appeal, but wanted to be clear that it followed the proper steps in denying the coverage.
The Cunninghams filed their suit on May 18, 2015, alleging that Aetna owed coverage under Ron Cunningham’s policy, which he obtained as an Oklahoma City firefighter. Orrana Cunningham was receiving treatment at Houston’s M.D. Anderson Cancer Center, and the doctors there recommended the proton beam treatment, according to their complaint.
Ron Cunningham mortgaged the farmhouse he had built with his wife in Meeker, Oklahoma, to obtain the roughly $90,000 he needed to pay out-of-pocket for the proton beam therapy, and after receiving the treatment his wife was improving and was released from the hospital, according to Terry.
On May 30, 2015, Orrana Cunningham died at age 54 of a viral infection that entered her brain and caused her brain stem to rupture, according to Terry.
The plaintiffs are represented by Doug Terry of Doug Terry Law and Justin D. Meek and Tom Paruolo of DeWitt Paruolo Meek.
Aetna is represented by John B. Shely and Laura Trenaman of Hunton Andrews Kurth LLP, Leasa M. Stewart of GableGotwals and Frederick P. Santarelli, Stewart J. Greenleaf Jr. and Sherine N. Bedlako of Elliott Greenleaf PC.
The case is Ron Cunningham et al. v. Aetna Life Insurance Company, case number CJ-2015-2826 in the District Court of Oklahoma County, State of Oklahoma.
Thank you to Law360
--Editing by Alanna Weissman.
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