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

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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.

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READER COMMENTS

Posted by

on
What if were bitten my a Union rattlesnake in a scorpion I your not treated when I went to every doctor here and hospital in town I have another number 81887784058184151492

Posted by

on
MY QUESTION IS, HOW LONG WOULD THIS BE IN EFFECT FOR? I HAVE TRIED SINCE 2001 TO PROVE THIS ABOUT MY INSURANCE, THAT THEY DENIED ME PROPER CARE WHICH HAS RESULTED IN MY TOTAL HANDICAPPED MOBILITY FOR LIFE. I WAS SUPPOSE TO RECIEVE A TPA INJECTION WHICH WOULD HAVE PREVENTED SOME OF THE PARAILIZATION TO MY LEFT SIDE IF I HAD RECIEVED IN TIME, BUT MY INSURANCE COMPANY PUT COST ABOVE CARE AND I'M THE PRODUCT OF IT. I CAN'T EVEN BEING TO TELL YOU THE EFFECT THAT THIS HAS HAD ON MY LIFE. IT HAS BEEN DEVASTATING TO SAY THE LEAST. ALSO, MY SON WAS FORCED TO LEAVE HIS DREAM CAREER TO HELP TAKE CARE OF ME. SO, BOTH OUR LIVES HAVE BEEN MANIPULATED BY THIS TOTAL FAILURE TO PROTECT ME THE PATIENT WHO HAS PAID SKY YHIGH PREMIUMS FOR WHAT I THOUGHT TO BE THE BEST COVERAGE.

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