Lawsuit Alleges Unreasonable Insurance Denial Puts Health at Risk

Philadelphia, PABad faith insurance lawsuits, alleging insurance companies have unreasonably denied disability claims, are nothing new. But now lawsuits are being filed against insurance companies alleging policyholders are being wrongfully denied potentially life-saving treatment on the basis they are not sick enough for treatment to be medically necessary.

One such lawsuit was filed by Shima Andre against Blue Cross of California, alleging breach of good faith, breach of contract and intentional infliction of distress.

Andre was diagnosed in late 2011 with hepatitis C, a contagious liver disease that can cause liver complications - including liver damage, liver cancer and death. Until October 2014, there was no consistent cure for hepatitis C (there was a three-drug treatment, but the cure rate was only 70 percent and there were severe side effects). In October 2014, the US Food and Drug Administration (FDA) approved a drug called Harvoni. Harvoni has been shown in studies to be 95 to 99 percent effective in curing hepatitis C, with few complications or side effects. Even better, it only requires treatment lasting between 8 and 12 weeks.

The catch? Harvoni is expensive, costing up to $99,000 for a 12-week treatment.

In the years following her diagnosis, Shima reportedly suffered diminished health. She experienced severe liver pains and had to delay having a child because childbirth could result in her offspring having hepatitis C, as well.

Once Harvoni was approved, Shima’s doctor reportedly requested the okay from Blue Cross to treat Shima. Blue Cross allegedly refused, finding the medication was Shima’s doctor appealed the denial, and the appeal was also denied.

According to court documents, Shima’s doctor attempted to contact Blue Cross reviewers directly to push for treatment, but Blue Cross refused to speak with him. The doctor again wrote an appeal, citing information from the American Association for the Study of Liver Diseases that all patients with hepatitis C - not just those with a certain level of liver damage - should be treated. Blue Cross again denied Shima’s complaint.

“Again Blue Cross told Shima that she would have to live with daily pain, depression, chronic fatigue, and wait until her liver drastically worsened before it would approve the medication. Blue Cross prefers that its insureds get much worse before paying for treatment almost guaranteed to cure their disease,” Shima’s lawsuit alleges.

In addition to forcing her to live with daily pain, Shima alleges she has had to continue delaying pregnancy out of concern for passing on hepatitis C to her offspring. Despite repeated communications from her doctor that the Harvoni treatment was medically necessary, Blue Cross has allegedly determined that is not the case.

Notably, the lawsuit also alleges there is no scientific backing for Blue Cross’s stance that the liver must be sufficiently damaged to approve treatment, nor is there evidence that the doctors reviewing Shima’s application have any experience in dealing with hepatitis C patients.

The lawsuit is Andre v. Blue Cross of California et al., case number BC582063 in Superior Court for the State of California for the County of Los Angeles.