A Judge Takes a Swing at an Insurance Company’s Denials
Robert Scola Jr. is a federal judge in Miami, and he’s just recused himself from a case involving the UnitedHealthcare (UHC) insurance company.
The case is one of two filed in Miami over the last two months claiming that UHC has improperly denied coverage for a specific cancer treatment. Scola calls that denial “immoral and barbaric.” He put those words on paper in his recusal order.
In his order, Scola outlined his personal reasons for standing aside. About two years ago, he was diagnosed with advanced prostate cancer and was offered proton radiation, the same treatment being denied to the patients who are suing UHC. A couple of years earlier, coverage for proton radiation treatment had also been refused to Scola’s close friend.
“All the experts opined that if I opted for radiation treatment, proton radiation was by far the wiser course of action,” the judge wrote in his order. “Although the Court (Robert Scola) opted for surgery, rather than radiation, those opinions [are] still resonant.”
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According to an article on the Modern Healthcare website, UnitedHealthcare considers proton radiation treatment to be “experimental and unproven.” Yet the U.S. Food and Drug Administration approved the treatment in 1988, and Medicare covers it. UHC says it “bases its medical policies and coverage decisions — including for proton beam therapy — on the prevailing published clinical and scientific evidence.” The lawsuits, however, claim the insurance company is denying the treatment simply because it’s expensive.
It’s not just cancer treatments that are denied
Has an insurance company ever denied you a treatment that a doctor told you would help your multiple sclerosis (MS)? Mine did, several years ago. I wanted to buy a Bioness L300, a functional electronic simulator that I needed to counter my left foot drop. Medicare would have covered the L300, but only for people with spinal cord injuries. People who needed it to treat a medical problem such as MS were out of luck. (For the most part, we still are.) Even though I had recommendations from my neurologist and my physical therapist, and medical records showed that it improved my walking and lessened my chance of falling, because Medicare wouldn’t pay for it, my insurance wouldn’t cover it, either. Two appeals were also denied.
Too bad the judge had to recuse
I sure wish that Scola could have remained sitting on this case, making use of his personal experience with insurance denials, but I understand that ethically he can’t. Wouldn’t it be something, though, if he could be called as a witness for the people who are taking their denials to court?
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Note: Multiple Sclerosis News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Multiple Sclerosis News Today or its parent company, Bionews Services, and are intended to spark discussion about issues pertaining to multiple sclerosis.
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Comments
Claudester Miller
I'm a Star Trek fan. I wish a vulcan mind - mold, including the body could be performed on those judges etc.,making decisions for us with MS. I would transfer MS to their bodies for two months. They could have their bodies back, then. Would it make a difference? Don't know, but they would know our struggle.
David Thomson
Yes life would be good again for 2mouths then they be like shite hit the fan ms do the care l think not
Christopher Paris
This is the moral battle; and where American ethics and compassion meet the road in conflict and combat with unfeeling and greed driven extortion: Dr. Death. We, the American people, whose ethic is FOUNDED on compassion need to unifiably become St.
George to protect innocent victims against Big Pharma and all, ALL its corrupt affiliate oligarchs.
THIS IS NOT STALIN'S GULAGS. This is fighting for equality and the God-given right for life. If our
well-intentioned advocating non-profits don't hold fast and persist with the moral battleground, then what's the point. We remain doomed. What are the players afraid of? Be heroic, for for God sake, heroic not only for present victims, but for all, the American ideal, to unilaterally share in our
benevolent initiatives for all. Too liberal a sentiment for you selfish, executing greed-mongers?
Same old big money big power oppressive tyrannts that have cursed we victims terribly of late. The successes of extortion do NOT make them acceptable
precedent. What has happened to our guts as a people of bless'ed vision? A nation as a refuge our Founders fought and died for? Where are you? What has stifled our unified Amercan voice of effective
opposition? Have we not had sufficient example: Buddha, Jesus, Muhammed and charity, presently, the Dali Lama, the world's saints and angels? How much
proof do you need to unifiably rally against evil djinns?
Georgia
I also believe all doctors, insurance companies in the medical profession, cover many truths from those that depend on them. For those like myself having multiple sclerosis,
to accommodate lifestyles and needs of Major Insurance Corporations. The Doctors and medical professionals we depend on, are giving false information to the general public. That is more than sad but criminal.
Andrea
I as well have MS in 2009 Coventry denied my procedure for months while declining during this time my Medicare was effective Feb 2010 was approved and in Chicago 6 days later. I am blessed but I would be 100% if Coventry would have covered this. My doctors and I had a conference call with Coventry them saying it wasn’t life or death well the procedure would have been much cheaper in the long term and I would be 100% in remission still. Needless to say I think Coventry among other insurance companies are worthless wait until someone close to them has a illness not covered!
Dale Degraffenreid
Amen to the last two. It is a shame the modern medicine is what it is. Money is their goal rather than helping someone with a critical health problem.
Cynthia King
Well, since you asked, I am on the hook for my first Ocrevus treatment to the tune of $72000. Just to be clear I have Medicare Advantage and also private insurance through my husband’s place of employment. Either one of two things happened: I was mistakenly placed in the 'self pay' column, or else one the big insurance company that bought the smaller company we had benefits through denied the prior authorization the smaller company allowed. To ice the cake, I knew none of this until I was sent to collections. Try to get benefits from a company that's no longer in business. I have spoken with my congressman, filed a complaint with the State of NY consumer affairs office, and the next step a lawyer. I guess I get choose how I become a ward of the state: have the medical lien levied and file for bankruptcy, or put all my assets in my husband's name and divorce him. It's nice to have options.
Ed Tobias
Wow, Cynthia, that's horrible.
I'm no insurance expert but I know that traditional Medicare paid for 80% of my Lemtrada treatments. Then my secondary insurance paid the remaining 20%. Did Medicare deny your Ocrevus claim?
Ed