Aetna was handed down a verdict by an Oklahoma jury that will require them to pay $25.6 million to the family of a cancer patient who died after the insurer denied coverage for proton beam therapy.
Jurors ordered the payment after ruling that Aetna failed to deal in good faith in determining whether or not to cover the procedure for Orrana Cunningham, a Oklahoma woman suffering from nasopharyngeal cancer, reported The Oklahoman.
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Proton beam therapy is type of external radiation therapy where clinicians use a beam of irradiated protons to target and shrink malignant tumors. While often criticized for its costs, proton beam therapy does generally hold less risk for side effects when compared to traditional X-Ray radiation therapy.
An Aetna medical director who reviewed the claim denied the coverage because they characterized the treatment as experimental, a decision upheld by two other doctors working for the insurer.
In response to the coverage denial, Cunningham’s family mortgaged their house and set up a crowdfunding page to help pay for the $92,000 cost of the therapy her doctors had prescribed. Even with these efforts, however, Cunningham died in May 2015 at age 54.
During the trial, jurors were told that the FDA has approved the use of the therapy in cancer cases and Medicare reimburses the use of proton beam therapy for beneficiaries.
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Additionally, the Cunningham’s lawyer Doug Terry presented evidence that Aetna’s doctors spent just minutes reviewing her case and in one instance one doctor complained to their Aetna supervisor that they were being forced to review more than 80 cases in a single day.
Earlier this year, California Insurance Commissioner Dave Jones launched an investigation into Aetna after one of its medical directors said under oath that he never even looked at patients’ medical records when deciding whether to deny or approve care.
In a 9-3 decision, Oklahoma jurors agreed that Aetna should $15.5 million in actual damages for emotional distress, another $10 million in punitive damage as well as the $92,082.19 cost of the procedure.
“We are disappointed with the verdict and are weighing our options for appeal,” Aetna said in a statement.
Two of of the jurors who dissented against the verdict said they believed that Cunningham’s family deserved even more in restitution.
“Orrana’s case exposes so much of what is wrong with health insurance,” the Cunninghams’ lawyer Doug Terry said in a statement.
“This case gave the jury a look behind the curtain so they could see what goes on at a health insurance company when they deny claims. The evidence showed Aetna’s denial of her claim involved overworked, under-qualified doctors working in the interest of their employer’s bottom line who are compensated in part based on the profitability of the company.”
Photo: Alex_str, Getty Images
