When Insurance Companies Deny Vital Treatment, What Can Patients Do?

Baltimore, MDThere are few business relationships as fraught with controversy as the relationships between healthcare providers and insurance companies. As illustrated in the Harvoni case, battle lines get drawn quickly. Add patients and a drug company into the mix and it would be difficult to find more complex relationships. Unfortunately, in these situations, the patient is stuck in the middle hoping for potentially life-saving treatment and wondering why profits are being put before patients.

Harvoni is a Hepatitis C medication, sold by Gilead Sciences. It is by all accounts highly effective, with a higher than 90 percent cure rate. It also comes with few side effects. That’s good news, because Hepatitis C is deadly, with more than 15,000 Americans reportedly dying each year due to Hepatitis C complications, including liver disease.

So what’s the problem? You might wonder. If there’s a drug that can cure a life-threatening disease and it comes with few side effects, why should there be an issue? The issue, some say, is the price tag. A 12-week treatment course of Harvoni costs around $99,000. Now, $99,000 for a life-saving treatment might still sound like an okay deal, but drug companies have allegedly told some patients that the treatment isn’t medically necessary.

Even worse, they’ve allegedly told patients the treatment isn’t necessary despite letters from doctors explaining the treatment is, indeed, necessary. So insurance companies are reportedly overruling doctors on the medical necessity of a drug with high effectiveness that treats a life-threatening disease.

No wonder the relationship between healthcare providers and insurance companies is tense.

So what would make the treatment medically necessary? According to court documents filed in lawsuits against insurance companies, if the patients have severe enough liver damage, the insurance company will approve Harvoni treatment. No word on if they would also pay for the added treatment the patient would now need due to the liver damage.

For now, lawsuits have been filed against some insurers, alleging they are in breach of contract for failing to provide coverage for medically necessary treatment. The lawsuits also allege that insurers have put profits before patients.

For their part, insurers argue that Harvoni was approved through a process that allowed for approval with less rigorous testing, meaning the drug’s effectiveness and safety have not been adequately studied.

Who the courts agree with remains to be seen.