A case against Blue Cross Blue Shield (BCBS) and Health Care Services Corporation was removed to Oklahoma federal court Friday. The suit comes following allegations that the insurance giant improperly denied coverage to the plaintiff for a cancer treatment using proton beam therapy. The plaintiff is seeking both punitive and compensatory damages.
The plaintiff was insured by BCBS under an individual health insurance policy, the complaint said. In August of 2019, he was diagnosed with anal cancer. Following his diagnosis, his doctors recommended that Proton Beam Therapy Radiation (PBT) would be the most effective course of treatment for his condition. After proceeding with the treatment, the plaintiff submitted an insurance claim requesting coverage of the PBT. His initial claim was denied by the defendants.
The plaintiff said he appealed this initial denial of the claim in August 2019 using both a standard appeal and an external review appeal. In these, he said he included letters from “MD Anderson Cancer Center in support of coverage for the recommended treatment.” Both of these appeals were denied by the defendant on August 30, 2019, according to the plaintiff.
These denials have purportedly continued despite the Plaintiff claiming that he “complied with the terms of the insurance policy required for coverage” and submitted the claims in a correct and timely manner. Since the plaintiff had an insurance policy with the defendant, BCBS had specific obligations to the plaintiff, specifically for coverage of “medically necessary treatment.” The plaintiff had doctors defend his condition, explaining that his treatment for the cancer was medically necessary through the “submission of evidence and information.”
Despite this, the complaint said, the defendants have continually failed to cover the PBT treatment. The plaintiff asserted that this was “unreasonable, improper, and in violation of the terms of the Policy.” He also argued that BCBS breached their contract with the him, leading him to seek damages of $75,000, interest, litigation fees, and any other relief deemed necessary and just by the court.