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Blue Cross Blue Shield Denial of Proton Beam Radiation Therapy Class Action

Insurance companies have the power to decide what kinds of tests and treatments patients receive. The complaint for this class action claims that Proton Beam Radiation Therapy (PBRT) was delayed or denied for cancer patients by Blue Cross Blue Shield of Florida, Inc. (BCBS).

Plaintiffs David Simpkins and George Cawthorn both are insured through BCBS. For Simpkins, the insurance came through an employer-provided plan which is governed by the Employee Retirement Income Security Act (ERISA), which the complaint says makes BCBS “a fiduciary” of the plan. Cawthorn had his coverage as a Medicare Advantage plan, governed by the Centers for Medicare and Medicaid Services (CMS) national coverage determinations. The complaint says that the contracts require “that BCBS cover all treatments that are medically necessary.”

PBRT provides radiation to a tumor while reducing the amount provided to healthy tissues. This results in fewer side effects and complications than the earlier Intensity Modulated Radiotherapy (IMRT) treatments, the complaint says: “With PBRT, protons deposit their energy over a very small area called the ‘Bragg peak.’ The Bragg peak can be used to target high doses of proton beams to a tumor, while doing less damage to normal tissues in front of and behind the tumor. Proton beams enable patients to tolerate higher total doses of radiation therapy…”

The complaint alleges that PBRT has been recognized “for decades” as an established treatment for cancer. According to the complaint, “PBRT has been around and well-accepted for over 30 years. The Food and Drug Administration (“FDA”) approved PBRT for treatment of cancer in 1988” and studies have validated its safety and effectiveness. Traditional Medicare plans have approved it for the treatment of various cancers.

The problem, the complaint says, is that it is more expensive than IMRT. It claims that BCBS “has established a uniform policy as to all participants or beneficiaries to deny or delay the treatment of PBRT, and force people to seek the suboptimal treatments and thereby attempt to save itself the cost of PBRT treatment.” 

Furthermore, “the fact that a physician has recommended or approved PBRT for any given patient is not a significant factor in BCBS’s analysis of whether the treatment is medically necessary.”  Instead, it performs its own Comparative Effective Analysis, comparing the cost of PBRT to other forms of treatment.

BCBS initially denied both plaintiffs coverage for PBRT.

The counts include unjust enrichment, implied-in-law contract, and improper denial and delay of benefits, among other things.

Two classes have been defined for this action.

The ERISA Class is all particpants or beneficiaries in an ERISA plan underwritten or administered by BCBS who, based on the application of the BCBS PBRT Policy, were delayed in receiving health insurance coverage for PBRT to treat their cancer.

The Medicare Advantage Class is all participants or beneficiaries in Medicare Advantage Plans underwritten or administered by BCBS who, based on the application of BCBS PBRT Policy, were delayed in receiving health insurance coverage for PBRT to treat their cancer.

Article Type: Lawsuit
Topic: Insurance

Most Recent Case Event

Blue Cross Blue Shield Denial of Proton Beam Radiation Therapy Complaint

January 16, 2020

Insurance companies have the power to decide what kinds of tests and treatments patients receive. The complaint for this class action claims that Proton Beam Radiation Therapy (PBRT) was delayed or denied for cancer patients by Blue Cross Blue Shield of Florida, Inc. (BCBS), claiming it was not an established treatment.

bcbs_of_fl_delay_of_cancer_therapy_compl.pdf

Case Event History

Blue Cross Blue Shield Denial of Proton Beam Radiation Therapy Complaint

January 16, 2020

Insurance companies have the power to decide what kinds of tests and treatments patients receive. The complaint for this class action claims that Proton Beam Radiation Therapy (PBRT) was delayed or denied for cancer patients by Blue Cross Blue Shield of Florida, Inc. (BCBS), claiming it was not an established treatment.

bcbs_of_fl_delay_of_cancer_therapy_compl.pdf
Tags: Denial of Benefits, Health Insurance, Insurance