Two cancer patients claim in a class action that BCBS has employed a policy and practice of initially denying claims for proton beam therapy only to reverse course later on after patients have endured a lengthy appeals process.
Blue Cross Blue Shield of Florida, Inc. (BCBS) is on the receiving end of a proposed class action in which two men claim the insurance company “unreasonably and unnecessarily” delayed coverage of proton beam radiation therapy based on a blanket policy that the cancer treatment is “experimental” and “not medically necessary.” BCBS has allegedly employed a policy and practice of initially denying claims for proton beam therapy only to reverse course later on after patients have endured a lengthy appeals process.
The lawsuit says that proton beam radiation therapy (PBRT), which uses protons to target radiation to a tumor site, has been a “well-accepted” cancer treatment for over 30 years. Moreover, the procedure, the case continues, is often favored over traditional intensity-modulated radiotherapy and other treatments because it minimizes damage to surrounding healthy tissue, thereby reducing complications and side effects. Despite the benefits of proton beam radiation therapy and specific recommendations from patients’ doctors, BCBS has routinely denied requests for coverage of the treatment with the reasoning that it is “experimental” or “not medically necessary,” the suit alleges.
According to the lawsuit, BCBS’s tract is to initially deny coverage for proton beam radiation therapy as a cost-saving measure given that it is more expensive on average than other treatments. The lawsuit alleges that instead of protecting the interests of the beneficiaries and participants in its health insurance plans, BCBS rules that the treatment is not covered under its policies and forces consumers to file an appeal, which can add weeks or even months to the treatment process, before ultimately reversing its decision.
“Only after this unreasonable and unnecessary delay, and after Plaintiffs and other putative Class members have been forced to expend time and funds due to the delay, will BCBS admit that the PBRT is covered under its policies and finally approve the treatment,” the complaint reads.
The case alleges that a side effect of BCBS’s delays is that many policyholders or participants, in the face of what the lawsuit describes as “literally, a life or death decision,” will “give up” and settle for less effective (and less expensive) treatment options instead of enduring the appeals process.
With regard to the plaintiffs’ situations, the men say the defendant ultimately reversed its decisions and approved their proton beam radiation therapy after they and their doctors endured multiple rounds of appeals.
The lawsuit seeks to cover all participants or beneficiaries in ERISA plans or Medicare Advantage plans underwritten or administered by the defendant whose coverage for proton beam radiation therapy for their cancer treatment was delayed based on the BCBS’s alleged PBRT policy.