According to court documents filed by Schneiderman, CDPHP has refused treatment of Hepatitis C to patients who have not yet demonstrated advanced disease. Signs of advanced disease include liver scarring, liver failure and other serious liver complications. Medical experts have said that all individuals with Hepatitis C should receive treatment for their infection because if left untreated, Hepatitis C is highly contagious and potentially fatal.
In 2013, the US Food and Drug Administration (FDA) approved new treatments for Hepatitis C. Those treatments - Harvoni and Sovaldi - have much higher success rates than previous treatments. But they’re expensive. Three months on Harvoni can cost almost $100,000. And it’s because of that price, plaintiffs allege, insurers have routinely denied policyholders with medically necessary treatments. Schneiderman alleges CDPHP denied almost half its members’ claims for effective Hepatitis C treatment.
Because CDPHP reportedly markets its plans as covering all medically necessary care, but has denied Hepatitis C treatment even though patients’ doctors have advised treatment, Schneiderman alleges CDPHP is breaching its duty to its members.
“Nothing in the plan documents would lead reasonable consumers to understand that they would need to wait for their medical condition to deteriorate for treatment to be covered by their health plans when they have a confirmed diagnosis of a potentially life-threatening disease, there is a medication that cures their condition, the medication is specifically approved by the FDA for that purpose, and the medication is on the plan formulary.”
Possibly worse, Schneiderman argues there are internal documents that show “CDPHP revised its Hepatitis C medical necessity criteria specifically to restrict coverage based on cost considerations.” Of course, members and potential members were allegedly not told that the cost of treatment is included in a consideration of whether or not that treatment is medically necessary.
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CDPHP is not the only insurance company alleged to have denied Hepatitis C treatment on the basis of cost. Blue Cross of California faces a lawsuit filed by Shima Andre, who alleges her application for Harvoni treatment was denied because her liver had not deteriorated enough to warrant treatment. Andre alleges Blue Cross violated its contractual obligation to her and put her health in jeopardy to protect profits.
Schneiderman’s lawsuit is People of the State of New York against Capital District Physicians’ Health Plan, Inc., in Supreme Court of the State of New York. The Andre lawsuit is Andre v. Blue Cross of California et al., case number BC582063, in the Superior Court of the State of California, County of Los Angeles.