America is one of the few developed countries that doesn’t have universal healthcare system which seems to be a big problem for Americans who have to choose between private health insurance coverage and public health insurance coverage. While both types of health insurances have their own pros and cons, most Americans choose the private health insurance coverage, which is understandably more expensive, but it still receives high marks and has higher market share.
Both the private and the government-run health care insurance coverage will work most of the times, but things get complicated when people need expensive treatments and this is when both of the insurance plans might fail to provide the support patients need. Such was the case recently, with a cancer patient who claims that her insurance company didn’t approve a life-saving treatment twice even though the treatment is FDA approved.
According to CBS46 that reported about the case recently, a woman was denied expensive cancer treatment twice in the last few months, but the insurance company later accepted her request and she underwent the much-needed treatment which was described by her doctors as ‘life-saving’ one. Claire Thevenot, who is a Ga. based nurse and patient care advocate, decided to speak out what she went through in an effort to raise awareness and help other people in fighting for their rights.
Thevenot was diagnosed with cancer years ago, but she managed to battle the deadly disease with a double mastectomy in 2018. However, cancer returned four months ago, but this time spots spread to her spine meaning that her life was at high risk and she needed special treatment as soon as possible. Her doctors named Stereotactic Body Radiation Therapy (SBRT) as her best chance for survival.
According to UCLA Health, SBRT is a targeted treatment as it sends a precise beam with high-intensity radiation doses to a specific cancerous spot. The treatment, which is expensive as it costs tens of thousands of dollars, is FDA-approved treatment and medical studies show the success rate can be 80 to 90% for ridding cancer spots. However, Thevenot was nothing but devastated when she received a denial letter from Aetna, a major healthcare insurance company, saying that her insurance doesn’t cover services that are not medically necessary additionally stating that there’s no current research that her specific cancer responds better to it than other types of radiation.
“You can’t even imagine how you’re going to handle something like that. It’s just devastating. “My first thought was I’m dying,” Thevenot said to CBS46 adding that her medical battle suddenly became a financial one too.
“The most shocking part of it, I think, is who gets to decide if it’s medically necessary. Common sense would tell you, the doctors get to decide.” Rep. Matt Wilson argued, “the healthcare professionals who have spent their whole career in medicine [should] get to decide.
Data provided by Change Healthcare shows that insurance denials increased by 23% in the last five years and 11% just since the start of the Covid-19 pandemic. Advocates blame insurers for systematically choosing profits over patients. Aetna faced lawsuit filed by other cancer patients who had been denied treatments similar to Thevenot’s one and a judge recently ruled in favor of the cancer patients saying that ‘the insurer wrongfully denied coverage because of costs, it ignored competent medical advice, and it improperly defined what’s considered a medical necessity.’
Fortunately for Thevenot, she was approved the treatment following her third attempt when she wrote a four-page letter to the insurance company. She cited additional studies and research to show why her life depended on the treatment. She underwent the treatment few weeks ago and is expected to fully recover.
The approval came just when a judge ruled in favor of the cancer patients that previously filed a lawsuit against the insurer. While Thevenot is not sure if the approval has something to do with the judge’s ruling, she remains huge patient care advocate and encourages everyone to fight for their rights as cancer treatments are time-sensitive treatments and should be taken seriously.