Miami, FL: Blue Cross is facing a denied insurance claim lawsuit over allegations it denies its policy holders access to a newly approved and expensive new hepatitis C drug made by Gilead Sciences.
According to the lawsuit, the medical insurer has refused its contractual duty to provide coverage for medically necessary treatments for a client who has had hepatitis C for 10 year, and others similarly situated. According to the lawsuit, lead plaintiff Janie Kondell was denied coverage because her "liver had not sufficiently deteriorated."
"In other words, defendant decided that Ms. Kondell hadn't suffered enough, and her liver hadn't been damaged enough, by a disease that causes irreparable harm and death, for which a cure is finally available,"the lawsuit states.
The US Food and Drug Administration approved the treatment, Harvoni, in October 2014. According to the complaint, the drug has a 95-99 percent cure rate. The once-daily pill can cost from $64,000 for an eight-week treatment to $99,000 for a 12-week treatment, and has few side effects.
According to the complaint, prior to approval of Harvoni, the existing treatment for Hep C, a contagious, chronic, potentially fatal condition resulting in liver damage, cirrhosis, infections, cancer, heart attacks and death, was only 70 percent effective and came with significant side effects.
"Hepatitis C is only the second disease or condition for which a cure has been discovered within a single lifespan of the disease or condition discovery," the complaint states. "Hepatitis C was discovered in 1990 and the cure was approved in 2014. Hepatitis C could be completely eradicated in a few years as a result of Harvoni, assuming patients, such as Kondell, have access to this incredible cure."
According to the complaint, Kondell has been a policyholder at Florida Blue for over 20 years. She was diagnosed with Hep C, and in February 2015 her physician prescribed Harvoni. Florida Blue immediately denied coverage, the complaint states. Although her doctor appealed the insurer' decision twice Florida Blue continued to deny coverage, claiming Kondell' liver wasn't severely damaged.
"No known medical study supports this denial, and nothing in Kondell' policy (or any of the class members' policies) grants defendant the right to withhold a potentially life-saving cure, particularly on the perverse and pretextual 'basis' that it is not 'medically necessary,'"the complaint states.
The complaint claims that Blue Cross is in violation of Florida' Deceptive and Unfair Trade Practices Act and breached the contract of all policyholders diagnosed with hepatitis C who were denied coverage. The suit is asking the court to demand Florida Blue cover the treatment and seeks unspecified damages in excess of $5 million.
Kondell is represented by Andres Rivero, Alan H. Rolnick, Charles E. Whorton and Daniel A. Sox of Rivero Mestre LLP. The case is Kondell v. Blue Cross and Blue Shield of Florida Inc., case number 0:15-cv-61118, in the U.S. District Court for the Southern District of Florida.