Proton Beam Therapy Insurance Coverage Denials – Class Action Investigation

CSK&D is investigating potential class action lawsuits against insurance companies based upon reports that some insurers may be denying patients with certain types of cancer coverage for proton beam therapy (“PBT”) treatment. PBT is a form of radiation therapy that relies on protons unlike more traditional treatment measures such as IMRT, which rely on x-rays.  PBT is used to treat certain types of cancer more effectively than IMRT and other treatments. Recent studies have proven PBT to be effective in treating many types of cancer without the debilitating side-effects associated with other treatments including tumors in the brain or spinal cord.  It can be also used in treating a number of other cancers, including breast cancer, prostate cancer, and melanoma.  Studies show that the reduction in treatment side-effects resulting from using PBT may be significant.

Under certain insurance companies’ policies and coverage parameters, coverage for PBT for certain types of cancer may not be indicated, despite medical studies and other medical academic literature indicating treatment effectiveness.  Insurers often adhere closely to their internally developed clinical guidelines when evaluating claims, reinforced by the expertise of their staff medical experts.  The result is that, despite what medical studies say about the effectiveness of PBT for a given type of cancer, insurance companies may deny coverage for PBT, classifying that treatment as experimental for a given cancer when, in fact, it is not.

As a result, cancer patients may be forced to pay for PBT out of their own pockets – a treatment which can cost $90,000 or more – and engage in lengthy post-denial appeal processes through their insurance company.  Reports indicate that insurance companies may be broadly denying insurance coverage for PBT in order to delay having to pay for these treatments even though the insurer knows treatment should be covered.  Some reports indicated that only when patients exhaust the appeals process, the insurance company will reverse their coverage decision.

CSK&D is specifically interested in speaking with insureds about incidences of PBT coverage denial whose insurance policies are unclear as to whether PBT is indicated for a given type of cancer, or where the policy clearly provides for PBT coverage but a claim was nevertheless denied.

If you or someone you know has experience with an insurance provider improperly denying coverage for PBT, please contact the lawyers listed below.

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Attorneys for this case:

Kimberly Donaldson-Smith
Andrew W. Ferich