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PAUL AND MARIA VanNocker are filing a federal lawsuit today on behalf of their 5-year-old son, Kyler, whose insurance company, HealthAmerica, refuses to pay for the latest treatment needed to prolong his life.
The complaint raises lots of questions that I assume will be answered at trial, should it come to that. The question it won't answer is one that's been gnawing at me since I first wrote of Kyler's plight in December:
How do HealthAmerica's overlords sleep at night?
I know my own dreams would be haunted if I acted as arbitrarily, capriciously and abusively - to borrow some pointed adjectives from the complaint - as the VanNockers allege HealthAmerica has regarding their little boy.
The Harrisburg-based company's denial of benefits to Kyler, the lawsuit claims, is the result of "a biased, self-serving misreading and misinterpretation" of everything from Kyler's medical records to the company's own internal documents.
The Harrisburg-based company's denial of benefits to Kyler, the lawsuit claims, is the result of "a biased, self-serving misreading and misinterpretation" of everything from Kyler's medical records to the company's own internal documents.
HealthAmerica's Kendall Marcocci told me yesterday that the company won't comment on pending litigation. Center City attorney David Senoff, though, was happy to explain why he is representing the Van Nockers for free in the lawsuit.
"These companies have to be brought to the courthouse to get them to do the right thing," said Senoff, a specialist in insurance disputes. "This child needs this treatment, or else."
He didn't need to explain what "or else" meant.
Readers may recall that Kyler has neuroblastoma, a rare, deadly childhood cancer that attacks the nervous system, creating tumors throughout his body.
He was diagnosed in 2007 and endured a year of medical treatment, with complications he barely survived. Thankfully, it knocked his cancer into remission for 12 lovely months, and he got to revel once again in the glories of childhood.
Last September, the disease came roaring back. This time, only one form of treatment, something called MIBG therapy, could help save his life.
But HealthAmerica refused to pay for the MIBG, which it considers "investigational/experimental" because there is "inadequate evidence in the peer-reviewed published clinical literature regarding its effectiveness." Nor is MIBG approved by the Food and Drug Administration, another criterion that HealthAmerica requires.
How come, then, asks the lawsuit, HealthAmerica covered not one but two prior therapies for Kyler that did not possess these supposed requirements?
What's yours USMB?
Ronnie Polaneczky: Parents suing to force insurance firm to cover their ailing son's therapy needs | Philadelphia Daily News | 02/09/2010
PAUL AND MARIA VanNocker are filing a federal lawsuit today on behalf of their 5-year-old son, Kyler, whose insurance company, HealthAmerica, refuses to pay for the latest treatment needed to prolong his life.
The complaint raises lots of questions that I assume will be answered at trial, should it come to that. The question it won't answer is one that's been gnawing at me since I first wrote of Kyler's plight in December:
How do HealthAmerica's overlords sleep at night?
I know my own dreams would be haunted if I acted as arbitrarily, capriciously and abusively - to borrow some pointed adjectives from the complaint - as the VanNockers allege HealthAmerica has regarding their little boy.
The Harrisburg-based company's denial of benefits to Kyler, the lawsuit claims, is the result of "a biased, self-serving misreading and misinterpretation" of everything from Kyler's medical records to the company's own internal documents.
The Harrisburg-based company's denial of benefits to Kyler, the lawsuit claims, is the result of "a biased, self-serving misreading and misinterpretation" of everything from Kyler's medical records to the company's own internal documents.
HealthAmerica's Kendall Marcocci told me yesterday that the company won't comment on pending litigation. Center City attorney David Senoff, though, was happy to explain why he is representing the Van Nockers for free in the lawsuit.
"These companies have to be brought to the courthouse to get them to do the right thing," said Senoff, a specialist in insurance disputes. "This child needs this treatment, or else."
He didn't need to explain what "or else" meant.
Readers may recall that Kyler has neuroblastoma, a rare, deadly childhood cancer that attacks the nervous system, creating tumors throughout his body.
He was diagnosed in 2007 and endured a year of medical treatment, with complications he barely survived. Thankfully, it knocked his cancer into remission for 12 lovely months, and he got to revel once again in the glories of childhood.
Last September, the disease came roaring back. This time, only one form of treatment, something called MIBG therapy, could help save his life.
But HealthAmerica refused to pay for the MIBG, which it considers "investigational/experimental" because there is "inadequate evidence in the peer-reviewed published clinical literature regarding its effectiveness." Nor is MIBG approved by the Food and Drug Administration, another criterion that HealthAmerica requires.
How come, then, asks the lawsuit, HealthAmerica covered not one but two prior therapies for Kyler that did not possess these supposed requirements?
What I said in the title says it all for my opinion.
What's yours USMB?
There is your answer. You would be outraged if an insurance company paid for non-FDA approved pharmaceuticals...so how can you expect the same company to pay for non-FDA approved cancer therapies?Nor is MIBG approved by the Food and Drug Administration, another criterion that HealthAmerica requires.
So now Insurance Companies are required to pay for unapproved treatments? For treatments that have no history of solving the problem?
Why hasn't the FDA approved the treatment?
I can almost buy the no history argument since any new treatment will fall in that category. But no FDA approval is a big one.
However, it was the only known drug to treat Kyler's condition, and he responded well to it. Four months later, HealthAmerica paid for another medication that wasn't FDA-approved for neuroblastoma treatment.
Again, Kyler responded well.
So why, pray tell, is HealthAmerica playing the "experimental therapy" card in the case of the MIBG treatment Kyler now needs? Gee, money couldn't have anything to do with the decision, could it?
In my December column, HealthAmerica's Marcocci was emphatic that her company declined Kyler's MIBG therapy not because of its cost but because of its experimental nature.
But that doesn't mean MIBG is ineffective.
"It's considered the standard of care in Europe and the United States for recurrent neuroblastoma," Kyler's oncologist, Stephan Grupp, told me then. "It's not an unproven treatment with no basis in medical science. Actually, the results are often very good."
There is your answer. You would be outraged if an insurance company paid for non-FDA approved pharmaceuticals...so how can you expect the same company to pay for non-FDA approved cancer therapies?
Health America's executives sleep at night knowing they are following FDA regulations. I thought you were a fan of greater regulation, Dogbert?
So now Insurance Companies are required to pay for unapproved treatments? For treatments that have no history of solving the problem?
Why hasn't the FDA approved the treatment?
I can almost buy the no history argument since any new treatment will fall in that category. But no FDA approval is a big one.
Regardless of how you describe MIBG, one thing became clear last week when Paul and Maria got the results of Kyler's latest tests to track his neuroblastoma.
The MIBG is working.
Children's Hospital, where Kyler receives much of his care, proceeded with two rounds of MIBG therapy for Kyler - at a cost of $110,000 - despite the VanNockers' inability to pay for it. (CHOP hopes that HealthAmerica will reconsider or that Medicaid will cover the MIBG cost; the VanNockers are Medicaid-eligible because they are bankrupt by medical costs).
"He's doing phenomenal," said Paul, noting that some of Kyler's many tumors have disappeared; others have shrunk in size and density. Kyler's improved condition now makes him eligible for treatment less toxic to his overall system than the "big guns" of MIBG.
That doesn't mean Kyler is out of the woods. His serious diagnosis ensures that his prognosis will always be uncertain.
But for now, because his internationally renowned neuroblastoma doctors, not his insurance company, is making the medical decisions, Kyler might make it to his sixth birthday in November.
The sad fact is, no matter how much money you spend on treatment, you can't cure everybody.
So now Insurance Companies are required to pay for unapproved treatments? For treatments that have no history of solving the problem?
Why hasn't the FDA approved the treatment?
I can almost buy the no history argument since any new treatment will fall in that category. But no FDA approval is a big one.
The sad fact is, no matter how much money you spend on treatment, you can't cure everybody.
Very good point.
We could spend unlimited amounts of money on each individual, even if the treatment has a near zero percent chance of working...but this would raise the cost of healthcare even higher.
Before you decide to blast me, see my post above this.
Children's Hospital, where Kyler receives much of his care, proceeded with two rounds of MIBG therapy for Kyler - at a cost of $110,000 - despite the VanNockers' inability to pay for it. (CHOP hopes that HealthAmerica will reconsider or that Medicaid will cover the MIBG cost; the VanNockers are Medicaid-eligible because they are bankrupt by medical costs).
$55,000 per round of experimental therapy? Conventional chemotherapy treatments cost roughly $2000 per round. For the price of these two MIBG treatments, over 50 people could receive traditional chemotherapy treatment.
And people wonder why healthcare is so expensive in this country? Nobody wants to draw a line...
The sad fact is, no matter how much money you spend on treatment, you can't cure everybody.
Very good point.
We could spend unlimited amounts of money on each individual, even if the treatment has a near zero percent chance of working...but this would raise the cost of healthcare even higher.
