Class-action lawsuit claims Aetna profits from denying cancer treatment

A putative class action lawsuit that alleges a major insurance carrier has systematically declined to cover a necessary cancer treatment purely because of its cost has jumped to federal court in the Middle District of Florida.

The allegations concern proton-beam radiation therapy, which targets tumors with energy from positively charged particles called protons, instead of X-rays.

The complaint accused Connecticut-based Aetna Life Insurance Co. of prioritizing money over policyholder’s health by relying on a policy that says the therapy is ”medically necessary” for patients under 21, but “experimental or investigational” where adults are concerned.

The lawsuit also points the finger at the School Board of Pinellas County for applying Aetna’s policy, alleging it sacrifices the interests of policyholders.

Kozyak Tropin & Throckmorton partner Maria Garcia in Coral Gables represents named plaintiff Scott Lake, the spouse of a school board member, who was diagnosed with prostate cancer in 2019. Lake claimed he couldn’t get coverage for proton-beam radiation therapy, even though his doctor said it offered the best hope for recovery.

Garcia said Lake’s predicament reflects a prevalent issue among health insurance companies, as many allegedly issue blanket policies denying the treatment without checking what’s in the best interests of the patient.

Garcia and colleagues Harley Tropin, Robert Neary and Frank Florio have teamed with Colson Hicks Eidson’s Stephanie Casey for the litigation.

Though proton-beam radiation therapy is more expensive than traditional cancer treatments, the plaintiffs’ team argued insurers are wrong to claim it’s experimental or lacking research. On the contrary, they say the medical community has recognized and recommended it as an appropriate treatment for decades, as it typically results in less complications and side effects.

“Those are just ways that they’re trying to avoid making it a treatment that they now have to authorize more often,” Garcia said.

The complaint alleges it was in Aetna’s interest to deny the more expensive treatment because the more money left in the school board’s account, the more interest the insurer could collect.

“It’s definitely an issue where they’re gaining financially because of these denials, which we find are inappropriate given the type of cancer that our patients have,” Garcia said.

There are hundreds of potential class members, according to Garcia, who’ve either had to forgo the treatment or pay for it out of pocket.

Spokeswoman Isabel Mascarenas said the Pinellas County school district denies the allegations.

“Pinellas County Schools denies wrongdoing,” Mascarenas said. “We are defending the action along with the counsel for our co-defendant, Aetna.”

Ardith Bronson and Maia Sevilla-Sharon of DLA Piper’s Miami office represent Aetna and did not respond to a request for comment by deadline.

Garcia hopes the litigation can spark change.

“We really are trying to help our clients get to a point where various insurance companies accept the reality that proton-beam therapy is now a treatment that is medically accepted and medically necessary for many patients, depending on the cancer that they’re suffering through,” Garcia said. “They want those policies to change, where people do get fair treatment and are given the medically necessary treatment that they need and that the physicians that follow them recommend.”

U.S. District Judge Virginia M. Hernandez Covington will preside over the litigation in the Middle District of Florida.