Colonial Life & Accident Oral Chemotherapy Benefits Class Action

Colonial Life & Accident Insurance Company offers a cancer insurance policy that covers “oral chemotherapy” drugs—but what exactly does it pay for? The complaint alleges that a sentence in the policy is at issue: “the cost of the prescription for the day you have the prescription filled, up to the amount shown in the Schedule Page.” The Schedule Page presents this as, “The amount charged up to $400/day; oral chemotherapy limited to $1200/month.”

Colonial issued a cancer policy to the plaintiffs in this case, Henry R. Seawell and Kathryn D. Seawell, which they have paid premiums on for a number of years. Kathryn was found to have metastatic breast cancer in 2016, and since then, she has been treated with the oral chemotherapy Ibrance and what the complaint calls “a supportive/protective drug regimen.”

Her prescription for Ibrance, the complaint says, is a cycle of twenty-one days on and seven days off, for a total of twenty-eight days. The total price for the drug is $13,000 per month, the complaint says, of which she has been paying a little over $830 per month in 2021.

The complaint alleges, “Thus, the Seawells expected Colonial to pick up the $1,200 maximum monthly allowance under the Policy, but Colonial claims it has no obligation to do so and has been reimbursing only $400 per month.” This is the question at issue in this class action, which centers on the meaning of the phrase “cost of the prescription for the day you have the prescription filled” with respect to Ibrance.

The complaint claims that Kathryn has lost $8,800 per year, over the past six years, in Colonial’s refusal to pay benefits for Ibrance. Since she will be on the drug indefinitely in the future, the problem is ongoing. Because Colonial has presumably taken the same position with other insureds as well, the complaint alleges that this may be an issue for other cancer patients.

The class for this action is all persons living in the US, who were issued a cancer policy with coverage for oral chemotherapy drugs, where (1) the policies were in force between July 15, 2016 and the date of final judgment in this case, and (2) under which coverages for oral chemotherapy drugs are “limited to the cost of the prescription for the day you have the prescription filled, up to the amount in the Schedule Page,” and (3) only as to those persons whose policies are no longer in force as of the date of this action, such persons incurred costs for oral chemotherapy drugs, made a claim under their policy for benefits, and Colonial refused to apply the monthly maximum in the Schedule Page in reimbursing a multi-day dosage dispensation of a prescription.

Article Type: Lawsuit
Topic: Insurance
Tags: Health Insurance, Incomplete payment of benefits due, Insurance