Nevada Supreme Court upholds $200 million verdict against insurer for denying protons

[IonsAreOurFuture]

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I don't know the details of this case but the size of the award caught my eye, especially the $160 M in punitive damages:

Nevada Supreme Court Affirms $160 Million Bad Faith Award
Sierra Health & Life Ins. Co. v. Eskew, 553 P.3d 441 (Nev. 2024).

The Nevada Supreme Court upheld a combined jury award of $200 million in damages against Sierra Health and Life Insurance Company for its bad faith refusal to cover proton beam radiation therapy for an insured who was battling lung cancer. After the insured’s death, his estate sued Sierra for bad faith. In a two-part trial, the jury awarded the estate $40 million in compensatory damages and $160 million in punitive damages. Sierra appealed to the Nevada Supreme Court, contending that the district court erred in denying its renewed motion for judgment as a matter of law on the bad faith claim. Sierra argued that it had a reasonable basis to deny coverage because the medical policy of its parent company stated that proton therapy was not medically necessary to treat lung cancer. The Nevada Supreme Court rejected that argument, finding “substantial evidence” from which the jury could conclude that Sierra knew it was not reasonable to deny a claim for proton therapy based on the policy. ...and there was substantial evidence that Sierra acted with “oppression.”

Dykema

California Supreme Court Finds Unfair Competition Law Claim Not Barred By Contractual Limitations ProvisionRosenberg-Wohl v. State Farm Fire & Cas. Co., 551 P.3d 1097 (Cal. 2024). When the insurer…

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My local insurance companies are also giving me "oppression." I should get a better lawyer 🙂

 

[thesauce]

The decision is completely wrong but I’m never siding with an insurance company

 

[drowsy12]

not for proton lobby however this will have downstream positive effects on acting as a deterrent to denying cancer therapies in general.

 

[ramsesthenice]

The decision is completely wrong but I’m never siding with an insurance company

This is the thing about civil law. It’s not unanimous and comes down to opinion. In this particular case, the insurance company got screwed. Badly.

But I’m with you. I wouldn’t mind seeing them have a little more motivation against denying SOC procedures and hiding behind necessity.

 

[grenz]

prior authorization is a PITA and the delays are bad for patients, but at ASTRO one audience member predicted that due to political pressures and bad press, insurance companies might start easing their prior auth but increasing denials of payment after the fact. This way patients and politicians would be happy, but doctors would be screwed. Might be a case of be careful what you wish for.

 

[CaesarRO]

prior authorization is a PITA and the delays are bad for patients, but at ASTRO one audience member predicted that due to political pressures and bad press, insurance companies might start easing their prior auth but increasing denials of payment after the fact. This way patients and politicians would be happy, but doctors would be screwed. Might be a case of be careful what you wish for.

Would politicians be happy?

It's outrageous to consider that this would be a "solution"

Need docs who knows how to get $160 million punitive damages from insurance companies for withholding payment after the fact

 

[yesmaster]

With the huge number of regulations in this country (thanks bureaucrats) it’s not surprising that being well-connected to good lawyers would be accretive in an industry like ours

 

[IonsAreOurFuture]

This is the thing about civil law. It’s not unanimous and comes down to opinion. In this particular case, the insurance company got screwed. Badly.

But I’m with you. I wouldn’t mind seeing them have a little more motivation against denying SOC procedures and hiding behind necessity.

When the insurance company gets to decide what is medically necessary, nothing is medically necessary.

Insurers are the de facto deciders of who gets what (and when) so really the only recourse some patients have is the law. Of course, by then it's too late to help the patient with active cancer.

I think this is the 3rd big trial case where the husband or wife got a jury award after their spouse was denied protons and died.

Usually there is a pattern of the insurance company arbitrarily failing to follow their own policy/ contractual obligations, plus not considering evidence beyond outdated internal policies, plus failing to provide radiation oncologists to do the case review, or just reading back the policy verbatim.

It's kind of where IMRT and SBRT denials were 10 years ago, minus the large lawsuits. In the absence of a randomized phase III trial showing benefit of IMRT over 3D, mostly it was an inability to meet published safety constraints that got IMRT approved for my patients, and the same now for protons if IMRT/VMAT cannot meet published constraints.

Insurers will still routinely deny protons even after I send letters showing in advance that they are knowingly exposing their patient to a high likelihood of major cardiac adverse events based on multiple missed constraints for mean heart dose, mean LAD and Max LAD dose. It sounds like something similar may have happened in the case above related to esophageal overdose. If radiation is a cardiotoxic drug like adriamycin, the insurance company is compelling me to knowingly inject unsafe doses, or no treatment at all.

They don't care, they don't have to, they're the insurance company.

 

[ramsesthenice]

When the insurance company gets to decide what is medically necessary, nothing is medically necessary.

Insurers are the de facto deciders of who gets what (and when) so really the only recourse some patients have is the law. Of course, by then it's too late to help the patient with active cancer.

I think this is the 3rd big trial case where the husband or wife got a jury award after their spouse was denied protons and died.

Usually there is a pattern of the insurance company arbitrarily failing to follow their own policy/ contractual obligations, plus not considering evidence beyond outdated internal policies, plus failing to provide radiation oncologists to do the case review, or just reading back the policy verbatim.

It's kind of where IMRT and SBRT denials were 10 years ago, minus the large lawsuits. In the absence of a randomized phase III trial showing benefit of IMRT over 3D, mostly it was an inability to meet published safety constraints that got IMRT approved for my patients, and the same now for protons if IMRT/VMAT cannot meet published constraints.

Insurers will still routinely deny protons even after I send letters showing in advance that they are knowingly exposing their patient to a high likelihood of major cardiac adverse events based on multiple missed constraints for mean heart dose, mean LAD and Max LAD dose. It sounds like something similar may have happened in the case above related to esophageal overdose. If radiation is a cardiotoxic drug like adriamycin, the insurance company is compelling me to knowingly inject unsafe doses, or no treatment at all.

They don't care, they don't have to, they're the insurance company.

Does anyone else have fun manipulating these sometimes? Take Evicore (not an insurer I know, but closely related). They still deny PETS for anal or vulvar/vaginal staging. So I get the CTs and make sure the interpreting radiologist knows what’s up because as they say, they can always find me something equivocal. I end up getting what I wanted and the f****** end up paying for both.

 

[radoncftw]

Does anyone else have fun manipulating these sometimes? Take Evicore (not an insurer I know, but closely related). They still deny PETS for anal or vulvar/vaginal staging. So I get the CTs and make sure the interpreting radiologist knows what’s up because as they say, they can always find me something equivocal. I end up getting what I wanted and the f****** end up paying for both.

i wouldn't say it is "fun", but you gotta do what you gotta do.
it annoys me that patients have to get 2 scans instead of 1 and that it delays when I can get the useful study.

 

[Reaganite]

prior authorization is a PITA and the delays are bad for patients, but at ASTRO one audience member predicted that due to political pressures and bad press, insurance companies might start easing their prior auth but increasing denials of payment after the fact. This way patients and politicians would be happy, but doctors would be screwed. Might be a case of be careful what you wish for.

This is exactly what's happening now. If you really follow your billing you realize pre auth/precert means nothing. It does not guarantee payment,and your claims can be denied on the back end for any number of reasons. The general strategy they seem to employ is to deny payment for some bogus reason and then make you jump over hurdle after hurdle to prove you deserve payment for the authorized service. And every time you have a new correspondence with them, they have like 30-60 business days to reply. Ultimately, they are just hoping your billing company gives up.

Doctor: "why didn't you pay me for that prostate imrt case you approved?"
Insurer: "oh, well, we have 120 days to pay a claim. Call back then."
Doctor: "it's been 120 days, where's my money?"
Insurer: "Oh, we didn't get the requested isodose lines."
Doctor: "you couldnt have told me that 120 days ago? We have a journal note in our emr documenting a correspondence with your company where u requested isodose lines to grant preauth. We were subsequently granted preauth because we sent those isodose lines."
Insurer: "Oh gee, I dont have any record we spoke, and we dont have any records of isodose lines being sent. Please re-send and we will get back to you in 30 days."
Doctor: "okay it's been 30 days. You got the isodose lines?"
Insurer: "Oh yes, but you didn't send those at the beginning so that preauth technically doesn't cover the procedure, so u need to resubmit claims. It should be noted we are also now past timely filing so you will need to file an appeal. Please contact us in 60 days."



This is a mostly true story.

 

[Haybrant]

was a reirradiation case or something? may reduced cord dose etc? or maybe a de novo case with a very high lung V20

 

[medgator]

Those guidelines have long been the subject of complaints from doctors. Over the past five years, organizations ranging from the American College of Cardiology to the Society for Vascular Surgery to ASTRO, the American Society for Radiation Oncology, have written to EviCore or regulators that the guidelines are flawed and can interfere with delivering the right care for patients. Benjamin Durkee, a doctor who chairs ASTRO’s payor relations committee, said EviCore had generally made “a good faith” effort to respond to the society’s concerns. But, he noted, the company continues to consistently deny a radiation treatment called proton beam therapy for some pelvic tumors that is more costly but supported by ASTRO’s recommendations.

Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Treatments

When companies like Aetna or UnitedHealthcare want to rein in costs, they turn to EviCore, whose business model depends on turning down payments for care recommended by doctors for their patients.

www.propublica.org

Great article for the most part other than that section

 

[NotMattSpraker]

Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Treatments

When companies like Aetna or UnitedHealthcare want to rein in costs, they turn to EviCore, whose business model depends on turning down payments for care recommended by doctors for their patients.

www.propublica.org

Great article for the most part other than that section

ASTRO has a payor relations committee? Is this secret or just mislabelled in the article? They have a corporate relations committee.

I do not know this physician at all, but pretty surprised he seems fairly young and works at an academic satellite.

Id love to hear what this committee says to payors.

 

[ramsesthenice]

ASTRO has a payor relations committee? Is this secret or just mislabelled in the article? They have a corporate relations committee.

I do not know this physician at all, but pretty surprised he seems fairly young and works at an academic satellite.

Id love to hear what this committee says to payors.

Well, the article isn’t a great look for ASTO if you really dig into the details. Of all the things PA they could have brought up, protons for pelvic tumors would be close to the bottom for me. The stated mission of PA is to reduce cost for unnecessary or unproven treatments. Unless they are referring to very select cases, they are venturing into making Cigna’s case for them.