Tag: Health Insurance

Policyholders Can Sue for Health Insurer’s Refusal to Cover Proton Beam Therapy Cancer Treatment Says Washington Supreme Court

On October 3, 2019, the Washington Supreme Court decided Strauss v. Premera Blue Cross, holding the Strausses could sue Premera Blue Cross for denying coverage for Proton Beam Therapy to treat prostate cancer.

Mr. Strauss had a Premera health insurance policy. The policy promised Premera would pay for “medically necessary” treatment. Mr. Strauss was diagnosed with prostate cancer and his doctor recommended Proton Beam Therapy treatment. Mr. Strauss’ doctor believed Proton Beam Therapy had fewer side effects than traditional radiation therapy because it exposes less of the body to radiation.

Premara refused coverage, claiming Proton Beam Therapy was not “medically necessary.” Premara said there was no proof Proton Beam Therapy had fewer adverse side effects than traditional radiation therapy. The Strausses filed a lawsuit.

Because there were no clinical studies on point, the Strausses supported their case with testimony from two radiation oncologists that Proton Beam Therapy would lead to fewer side effects because it exposed less of the body to radiation. Premera argued the Strausses could never prove Proton Beam Therapy was medically necessary without clinical studies. The trial court agreed with Premera and dismissed the lawsuit.

The Washington Supreme Court reversed, holding the Strausses’ case could move forward. The Supreme Court emphasized the absence of clinical evidence did not bar the Strausses’ claim. The Supreme Court found the Strausses’ expert doctors were qualified and that the trial court was wrong to reject the doctors’ opinions purely because no clinical studies existed. Importantly, the Supreme Court also rejected certain prior cases Premera relied on, holding those cases were wrongly decided.

The Strauss case is an important victory for policyholders and patients. Health insurance disputes can be very difficult, particularly because health insurance policyholders often have fewer consumer protections and are at greater risk of abuse by their insurers. Health insurers often use the words “medically necessary” as magic words that mean you have no right to the healthcare your doctor prescribed. This is especially true with novel treatments for complex diseases like cancer. This ruling will hopefully empower more people to pursue the treatment they need without worrying about insurance coverage.

Washing State’s “homegrown” health insurers credited with keeping rate increases low

Preliminary reports suggest Washington State’s Affordable Care Act (a/k/a Obamacare) plans will see minimal rate increases in 2020. Washington State exchange plans are projected to see a 1% average rate increase, lower than almost half of other states in the U.S.

Washington’s Insurance Commissioner reportedly credited Washington-based health plans with the low increases. Washington-based insurers are tied to the local community. These insurers rely on keeping local business in order to thrive. Local plans also tend to have better relationships with doctors and hospitals. Large, national carriers, on the other hand, can lose Washington customers to cheaper plans.

This is good news for the approximately 250,000 Washington residents who buy insurance through Washington’s ACA/Obamacare exchange.

Washington State Bans Surprise Medical Billing

We previously blogged about the push by Washington’s Insurance Commissioner to ban so-called surprise medical billing, i.e., where an insured gets hit with a huge bill for medical treatment despite going to an in-network provider or seeking emergency care.  In those circumstances, the insurer claims the hospital’s bill is too high and refuses to pay, and the hospital bills the patient for the difference.  This practice (known as “balance billing”) results in the policyholder getting a huge hospital bill for medical care that was covered by their insurance policy, even if the policyholder used an in-network provider and did everything right.  In these situations, the patient is stuck in the middle with the insurer and the hospital each blaming the other for the huge balance bill.

Washington’s surprise medical billing ban has now been signed into law by the Governor.  The new law is touted as one of the strongest legal protections for health insurance policyholders and patients in the country.

Among other things, the surprise medical billing ban includes the following:

  • Bans balance billing where you receive emergency medical treatment, even if it’s at an out-of-network facility – this includes seeking emergency medical treatment in a state bordering Washington State;
  • Bans balance billing where you obtain treatment from an in-network provider, regardless of whether it’s an emergency;
  • Requires insurers to pay out-of-network providers directly (as opposed to leaving the policyholder to fend for themselves.

One of the most significant reforms is that the new law requires insurers and medical providers to resolve billing disputes between themselves, rather than leaving the patient to deal with the excess bill from the provider.  This is a huge win for policyholders and patients because it means patients are no longer left holding the bag when the insurer and doctor disagree over the medical bills.  Insurers and hospitals have the resources to fight medical billing disputes and the bargaining power to keep them from happening in the first place – patients do not.  The new law fixes a major injustice by preventing insurers and providers from imposing on patients the burden of resolving medical billing disputes.

Washington’s surprise medical billing reform is a big step forward for patients and health insurance policyholders.

 

 

Washington State Enacts “Public Option” Health Insurance Plan

This week, Washington State passed a new law designed to offer consumers a so-called “pubic option” for buying health insurance.  The general idea is that the state will launch its own health insurance program to compete with the marketplace.  Unlike Medicare or Medicaid, anyone would have the option to purchase coverage through the “public option.”

The public option is targeted at taking the pressure off of people who don’t receive health insurance through their employer, but make too much money to get subsidized coverage through the Affordable Care Act (a/k/a Obamacare).  Folks in this situation, often small business owners or the self-employed, have struggled with substantial premium increases in recent years.

The public option is not true insurance.  Instead, Washington State will contract with insurance companies to administer the system under the state’s control.  The main idea is that the public option caps the amount it will pay doctors, hospitals and other medical providers at 160% of the rate Medicare would pay for the same services.  Medicare rates are typically quite low compared to what an uninsured patient would pay.

The public option is hoped to avoid the steep premium increases that have become an annual routine for most health insurance.  Rates increased 13.8% in 2019; they increased 36% in 2018.

Other states, including Colorado and Connecticut, are considering similar legislation.

Aetna Settles Wrongful Depression Treatment Denial Allegations

On February 15, 2019, Aetna Inc. announced a settlement of allegations Aetna wrongfully denied mental health treatment.  The plaintiff and a group of Aetna insureds had filed a class action lawsuit under ERISA alleging Aetna wrongfully denied health insurance for a specific treatment for major depression called Transcranial Magnetic Stimulation (“TMS”).

The lawsuit alleges Aetna had a uniform policy of denying coverage for TMS on the basis TMS was purportedly “experimental and investigational.”  Experimental/investigational exclusions are common in health plans, particularly plans issued through employers under ERISA.  In theory, such exclusions limit the insurer’s obligation to pay for treatment where there’s insufficient evidence the treatment will effectively treat the insured.  Unfortunately, in practice, experimental/investigational exclusions are frequently used as a justification for health plans’ refusal to cover any treatment that is new or novel enough to be expensive.

If approved by the judge, the settlement would require Aetna to pay $6.2 million to reimburse insureds who were wrongfully denied coverage for TMS treatment.  Aetna had already changed its policies to allow coverage for TMS earlier in the lawsuit.  The settlement class includes participants in employee-sponsored health plans administered by Aetna who were denied health insurance coverage for TMS on the basis of Experimental, Investigational, or “Unproven Services.”