Fighting for Your Insurance Coverage

At Leopold & Associates, almost all of our cases deal with fighting insurance companies.  Insurance companies are paid premiums to provide coverage, reimbursement and protection to people when things go wrong.  We all know mistakes happen and we all also hope to be covered by insurance to help guard against the unforeseeable.  Sometimes that can be reimbursement for medical expenses after a car accident or coverage for future medical care if a doctor makes a mistake. At its most basic, we carry health insurance to guard against catastrophic medical expenses such as a serious injury or cancer diagnosis.  We count on the insurance that we, or an employer, pays for to cover those expenses.  When an insurance company denies you coverage, trying to fight for your benefits you are entitled to while battling an injury or illness, can feel like fighting the weight of the world.

Last week, in a story similar tof John Grisham’s fictional book, and later movie, The Rainmaker, Aetna, one of the largest health insurance companies in the country was hit with a $25.5 million dollar verdict for denying lifesaving cancer treatment to an Oklahoma woman.  As CNN reported, in 2014 Orrana Cunningham, was diagnosed with stage 4 nasopharyngeal cancer near her brain stem.  Doctors wanted to treat the cancer with proton beam therapy, a common form of radiation.  Aetna denied the claim arguing that this treatment was “experimental.”  Orrana died of complications from the cancer in 2015 at the age of 54.

There is nothing experimental about proton beam therapy.  The treatment has been around for decades and is covered by Medicare.  Proton beam therapy is a focused form of radiation that can target a specific area in the brain with a tumor.  In Orrana’s case, her doctors argued that without this treatment, they would have to use a less effective traditional radiation that could also cause blindness and memory loss.  As Dr. Andrew Chang, an oncologist who testified at the trial against Aetna stated, “nobody in the oncology community considers proton therapy experimental for the treatment of cancer.”

Nevertheless, Aetna continued to refuse the claim which effectively denied Orrana timely lifesaving treatment.  After losing precious months fighting her insurance company instead of her cancer, Orrana and her husband mortgaged their house and set up a Go Fund Me campaign to help pay the roughly $92,000 to get this treatment.  And by all accounts, it was working.  The tumor was shrinking.  But it was too late.  The delay was deadly.

At trial, Aetna’s attorneys argued the company did nothing wrong.  Their lead lawyer, John Shely, even thanked the doctors who denied the coverage in his closing argument and said he was proud of them.  The jury disagreed and found that Aetna “recklessly disregarded its duty to deal fairly and act in good faith with the Cunninghams.”  They awarded $15.5 million for emotional distress and $10 million in punitive damages aimed at punishing Aetna and sending a message to other insurance companies that this conduct is wrong.

We hope that other insurance companies get the message.  Every week we get calls from Chicago residents fighting with insurance companies, often for basic benefits that they have paid for and expect to have.  If you are reading this and find yourself in a similar situation, we recommend immediately taking the following action:

  1. Ask your doctor to put a letter in your file explaining the necessity of the treatment they are ordering and why such treatment is standard in the medical field.
  2. Ask your hospital if they can provide you with a patient advocate who can work with your insurance company to get the benefits and coverage that you are entitled to.
  3. Speak with a lawyer about your options to see if there is any help that can be provided under the law.It is a good idea to have a copy of your insurance information and any policy coverage documents, denial letters or explanations of benefits ready for review.

We understand how frustrating it can be to fight against what seems like endless runarounds, hold times and promises of return calls. Insurance should be there to help you, not prevent you from getting the coverage you paid for.  It is our hope that trial lawyers will continue to fight for patient’s rights so that insurance companies can get the message and reform their practices.

Unfortunately, this message still seems lost on Aetna.  According to CNN, after the verdict was read, Aetna’s lawyer John Shely walked up to Orrana’s husband Ron, “congratulated him after the verdict before telling him he’d lose on appeals.”