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Consumers Win in Mich. Insurance
Case
In a case with potentially national ramifications, Blue Cross
& Blue Shield of Michigan has agreed to pay for high-dose chemotherapy and
bone marrow and stem cell transplants for cancer patients who were formerly
denied coverage.
Lisa Gleicher, the Detroit attorney who litigated the case, called
the settlement a “victory for consumers, who too often are the ones who
get overlooked in this big, big business of health care.”
Gleicher represented more than 120 people, most of them in a class
action suit heard in Wayne County Circuit Court, in an effort get Blue Cross to
broaden its coverage for persons needing high-dose chemotherapy and a stem cell
transplant for breast cancer. The insurance company previously limited coverage
to just a few specified types of cancer.
Gleicher’s involvement with cases of this type goes back to
about 1990. At that time, she said, Blue Cross was routinely denying coverage
of high-dose chemotherapy for women with breast cancer, contending the
treatment was “experimental” and “investigational.” About a
dozen women asked her to represent them and she filed a class action suit on
their behalf. In summer 1992 before the case came to trial, Blue Cross settled
out of court after losing a similar case that was tried in Michigan’s
Upper Peninsula.
“We thought we had scored an important victory,”
Gleicher said. “But unbeknownst to us, Blue Cross approached the Michigan
Insurance Bureau to change the language of what they covered. They added riders
to everybody’s policies, including one called ‘Rider BMT,’ that
exclude coverage of high-dose chemotherapy for all but five diseases. And
because the only people the Insurance Bureau ever talks to are from insurance
companies, they let them get away with it.
“Pretty soon I started getting calls again,” Gleicher
remembered. “For a while, I didn’t know what to do. I felt like
I’d won the battle but lost the war.”
Gleicher is nothing if not persistent, however, and decided to
keep fighting. After considering alternatives, including basing the suit on
constitutional grounds, she ran across a Michigan statute that had been on the
books since 1989, but which nobody seemed to be taking into account. It stated
simply that insurance companies were required to cover high-dose chemotherapy
for cancer if the therapy met five straightforward criteria. Transplants were
included in the coverage as necessary adjuncts to the chemotherapy.
Gleicher filed the class action suit in a Michigan circuit court
in February 1996. At the same time she also represented about two dozen people
in individual cases in federal court because their insurance benefits were
covered by federal statutes.
Both the federal and circuit court judges ruled that the law
required coverage, Gleicher said. After losing the first few cases in federal
court, Blue Cross & Blue Shield saw the writing on the wall. The insurer
settled the class action suit and the remaining federal cases in August 1997,
agreeing to pay for complete coverage for all of Gleicher’s clients.
One of those clients was Eva Navarro, whose court victory resulted
in coverage for a stem cell transplant. “People like to bash lawyers, but
I’m convinced my lawyers saved my life,” Navarro said.
Another client, public health nurse Vicki Sluiter, said, “She
[Gleicher] just hung in there for so many people.”
“It’s bad enough having cancer and then having to worry
about the money,” said Jan Banaszak, a breast cancer patient whom Gleicher
represented in federal court. “Blue Cross will take care of me now.”
The settlement is important because Blue Cross & Blue Shield
often sets the standard for medical coverage—not just in Michigan, where
it accounts for more than 50 percent of commercial health insurance, but in the
rest of the country as well.
Dr. William Peters, president of the Barbara Ann Karmanos Cancer
Institute in Detroit, called the settlement “one of the most important
advances that has ever happened in cancer.” He also said, “Blue Cross
should be commended. This will benefit patients for years to come.”
Says Gleicher: “Everyone in Michigan will follow the Blues
and expand their coverage for high-dose chemotherapy and related transplants.
They’ll have to if they want to compete in this market.
“What I’d like to see now is federal legislation,
possibly modeled on these pro-patient Michigan laws, that says these are no
longer ‘investigational’ procedures we’re talking about, but the
acknowledged standard of care.
“That would be a real victory for consumers.” |
