While our Florida insurance claims law firm handles all types of insurance claims disputes, the most typical insurance disputes involve financial loss in the form of damaged or destroyed property.  If a health insurance carrier denies a claim for potentially lifesaving treatment to a patient with cancer or another life-threatening disease, the stakes are much higher.  Further, the consequences of a denial can be devastating not only for the policyholder but for loved ones affected by the decision.  A recent court decision from another jurisdiction demonstrates the stakes when a health insurance carrier tries to place saving a few bucks above an insured’s chance at a prolonged life.

The outcome of a Texas case was good news for a cancer patient who prevailed over his health insurance company.  The insured developed advanced prostate cancer and was being treated at MD Anderson in Houston.  The insured’s doctors recommended that his treatment include Proton Radiation Therapy.  While there were other potential regimens for the cancer based on its type and staging, the alternative modalities of treatment were not considered safe by the insured’s doctor.  The patient was determined to be a poor candidate for other possible treatments because of his history of Type II diabetes.  The insurance carrier refused to cover the treatment despite the opinion of the insured’s doctors.  The insurer’s denial was based on the contention the treatment was experimental.

When the policyholder filed a lawsuit based on the denial of coverage, the trial judge ruled in favor of the policyholder.  Evidence presented to the court provided that the patient was receiving treatment from top doctors at a renowned cancer treatment center.  The treating physicians who determined the treatment was appropriate had been using Proton Radiation Therapy for over a decade.  Further, the National Association for Proton Therapy website indicated that “[p]roton beam therapy is neither experimental nor investigational.”  It is an established form of treatment that is widely accepted by physicians, government agencies, and many insurers, including Medicare and Medicaid.

The trial judge relied on this evidence in finding that the insurer was required to cover the cancer treatment.  These cases are tragic because many times insurers play God by concluding that a patient’s life is not worth the cost of treatment.  Many cases do not end with this type of positive outcome because an insurance company representative will second guess doctors regarding a cancer patient’s treatment. 

Many insurance companies deny life-saving treatment based on a decision by an individual with no qualifications or history treating the particular patient.  If you are denied insurance coverage for treatment of a serious or potentially fatal medical condition, you might have a right to pursue a lawsuit for breach of contract and/or insurance bad faith depending on the circumstances.

You can reach Miami Insurance Claims Lawyer J.P. Gonzalez-Sirgo by dialing his direct number at (786) 272-5841, calling the main office at (305) 461-1095, or Toll Free at 1 (866) 71-CLAIM or email Attorney Gonzalez-Sirgo directly at [email protected].

J.P. Gonzalez-Sirgo
J.P. Gonzalez-Sirgo, P.A.
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