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Were You Denied Proton Beam Therapy by the Insurance Company to Treat Your Cancer?

Proton therapy irradiates cancer cells with a beam of protons inside the tumor.

Proton beam therapy has become increasingly popular as a form of cancer treatment, but because it costs more than standard radiation, insurance companies routinely refuse to cover it. Often, insurance companies have policies in place classifying proton beam therapy as experimental or investigational. Based on these policies, insurers issue blanket denials of coverage requests without considering the patient’s request and assessing their individual case. Courts have found this type of conduct to be an example of insurance bad faith and have criticized this insurance tactic in the harshest terms.

If you have been denied coverage for proton beam therapy to treat your prostate cancer or another form of cancer for which your doctor recommended proton therapy, the insurance denial legal team at Gianelli & Morris wants to hear from you. Call our experienced and successful California bad-faith insurance attorneys for a free consultation to discuss your potential claims.

What Is Proton Beam Therapy?

Proton beam therapy, aka proton therapy, is a form of radiation therapy used to treat certain kinds of cancer. High-energy proton beams are targeted at cancer cells, disrupting their genes, killing them and keeping them from replicating.

Proton beam therapy differs from standard radiation therapy in that it fires protons at the cancer cells rather than x-rays. The advantage of the proton beam is that it is more precise and can be more selectively targeted only at the cancer cells, leaving nearby healthy tissue largely undisturbed. The proton beam can also be customized to fit the size, shape and depth of the tumor in the body, further increasing its precision.

The advantages of proton therapy make it especially useful to attack cancers in sensitive areas of the body that would not tolerate high doses of standard radiation, including the brain, heart and lungs. Because of its precision, proton therapy can direct a higher dose of radiation toward the cancer tissue than standard radiation, making it more effective. Proton therapy can also be used for longer periods and multiple treatments or to attack recurrent cancer, which is often ill-advised for standard radiation. Patients also report fewer and milder side effects with proton therapy compared to other forms of radiation.

Guess Why Insurers Don’t Like Proton Beam Therapy

Proton beam therapy isn’t cheap. A single treatment can cost tens of thousands of dollars, even over a hundred thousand dollars. Compared to standard x-ray radiation, proton therapy costs about 60% more. In all likelihood, this is the reason behind the many denials of proton beam therapy insurance companies routinely throw out.

Of course, insurance companies don’t outright base their denials on cost. Instead, they say proton therapy is “experimental,” “investigational,” or “unproven.” Yet the facts of the matter prove this simply isn’t so. Proton therapy has been approved as a cancer treatment by the Food and Drug Administration since 2001. It is widely accepted by physicians and leading hospitals around the country, and even by some health insurers, including Medicare and Medicaid. Many medical researchers believe proton therapy should be the standard treatment for certain types of cancers.

Judges and Juries Agree That Proton Therapy Is Useful and Insurance Denials Are in Bad Faith

There have been several cases in recent years where patients have taken insurance companies to court over their refusals to cover proton therapy. Tragically, some of these lawsuits have been pursued by the surviving family members of cancer victims who succumbed to their illness while battling the insurance companies to pay for the life-saving treatment they desperately needed but never got. Judges and juries who have heard these cases have been resounding in their denunciations of what they see as bad faith on the part of the insurance companies.

In 2018 an Oklahoma jury decided Aetna Health and Life Insurance Company was “reckless” and acted in bad faith by denying proton beam therapy. That jury awarded $25.5 million to the family of a 54-year-old woman whose proton treatment for cancer near her brain stem was denied coverage as “investigational and experimental.” Her family had been reduced to raising money for treatment through a GoFundMe campaign when she unfortunately died.

In 2019, plaintiffs banded together in a class action against UnitedHealthcare for its denial of coverage for proton beam therapy as unproven to treat prostate cancer. The federal judge in Florida who was overseeing the case had to remove himself from the case. As a prostate cancer survivor himself, the judge had personal knowledge of the insurance company’s demonstrably false claims that prevented him from serving as an impartial judge of the law in the case. In the judge’s own words, “It is undisputed among medical experts that proton radiation therapy is not experimental and causes much less collateral damage than traditional radiation. To deny a patient this treatment, if it is available, is immoral and barbaric.”

UnitedHealthcare updated its policies to accept that proton beam radiation is “proven” and “clinically equivalent [to standard radiation] for treating prostate cancer.” This apparent change of heart hasn’t kept them from denying the treatment, however. Last year a jury in Las Vegas delivered a verdict against UnitedHealthcare subsidiary Sierra Health and Life Insurance Company to the tune of $200 million for denying proton therapy in bad faith. As a sign of just how egregious the insurer’s conduct was felt to be, the $200 million award was composed of $40 million in compensatory damages for the harm suffered by the plaintiff, while the balance of $160 million was in the form of punitive damages intended solely to punish Sierra Health and Life for its bad faith denial. Punitive damages also serve as a wake-up call to other potential defendants and will hopefully deter other insurers from engaging in similar conduct.

Call Gianelli & Morris if Your Insurer Is Improperly Denying Your Cancer Treatment

Proton beam therapy is a life-saving treatment for many people who don’t have time to waste arguing with their insurer over whether the treatment has been proven effective or not. If you’ve been improperly denied the treatment your doctor recommends because the insurance company doesn’t want to pay for it, the experienced and dedicated bad-faith insurance attorneys at Gianelli & Morris will fight for you and fight to get you the medical care and compensation you need and deserve. Call us today or contact us online to schedule a free consultation and find out how we can help.

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