Insurer Can Be Held Responsible for Delay in Cancer Treatment

If your health insurer denies coverage for a particular procedure or course of treatment, it’s critically important to talk to an attorney. That’s because in many states there’s an official external review process in which the decision might be overturned. If a wrongful delay in treatment ends up causing you medical problems, you may be able to obtain damages in court as a result of the insurer’s failure to honor its contract with you. Take a recent case out of Minnesota. In that case, a man was diagnosed with bone cancer in March 2014. After two surgeries, his physicians recommended that he receive proton-beam radiation therapy. But his insurance policy with Blue Cross Blue Shield Minnesota considered the procedure investigative when treating the thoracic spine, where the tumor was located, and under its contract BCSBM wouldn’t pay for services that weren’t medically necessary or that were related to “investigative care.” A radiation oncologist sent a letter to BCBSM describing the procedure as medically necessary, but the insurer still denied it. The patient appealed the decision, but by this time nine months had already gone by and the tumor was wrapped around his spinal cord. Again, the insurer denied coverage. The patient then requested external review pursuant to state law, and just over a year after the initial diagnosis the reviewing panel overturned the denial of coverage. BCBSM paid for the therapy. The patient then took BCBSM to court, alleging that the denials were a breach of his insurance contract. A lower court dismissed the case, finding that there was no breach because BCBSM ultimately paid. But the state court of appeals overturned the decision, deciding that because the external reviewer found that the procedure was, in fact, a medical necessity under the contract, the patient could bring a case accusing the insurer of violating it.

About John Fagan

John is a Jacksonville native who grew up on the First Coast. He graduated from Bishop Kenny High School in 1975 and went to college at Florida State University where he completed a 4-year program in 3 years. John graduated from the Florida State University College of Business in 1978 and went straight into Florida State University College of Law. While in law school, John earned a position on the prestigious Law Review Board serving as its Business Editor. As a law student, John studied in the Oxford program. He also interned with the Florida Legislature working in the Florida House of Representatives Criminal Justice Committee. John was admitted to the Florida Bar in 1981. John began his legal career as a law school intern in the State Attorney's Office in Jacksonville in 1981. After his internship, legendary State Attorney Ed Austin hired John as a full-time Assistant State Attorney for the Fourth Judicial Circuit (Clay, Duval, and Nassau Counties). As a prosecutor, John tried jury and non-jury trial on charges ranging from DUI to Murder. In 1983, John moved from the State Attorney's Office to begin his career in private practice. He has practiced law for 30 years on the First Coast. For the last 20 years, John and his family have made Clay County their home. John limits his practice to personal injury and disability cases. While there are many fine attorneys in Clay County, John is one of only a few Clay County attorneys who limit their practice to personal injury and disability cases. John takes pride in helping clients resolve injury claims in ways that avoid the stress, uncertainty, and the expense of unnecessary litigation. Professional Activities John is the past President of the Clay County Bar Association and has served on the Board of the Clay County Bar Association from 2009-2013. He is an active member of the Florida Bar, and the Federal Bar of the Middle and Southern Districts of Florida. He is also a member of the American Association of Justice, the Florida Association of Justice, the National Organization of Social Security Claimants' Representatives, and the National Organization of Veterans' Advocates. Service to the Community John is involved in the Clay County Community serving as a member and Director of the Rotary Club of Orange Park, of the Clay County Bar Association, and the Putnam County Bar Association.
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