Class Action Claims Aetna Wrongfully Denied Coverage for Proton Beam Therapy

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A Pennsylvania man and his wife have filed a proposed class action lawsuit in which they claim Aetna Life Insurance Company and Aetna Inc. have wrongfully refused to cover the cost of cancer-treating proton beam therapy for members of the company’s healthcare plans.

The plaintiff says he was prescribed proton beam therapy after he had about 80 percent of a brain tumor removed in June 2017. According to the lawsuit, this type of post-operative radiation treatment has been “recognized for decades” by the medical community and the U.S. Food and Drug Administration as an “established, medically appropriate” treatment for cancer. Aetna, however, allegedly denied coverage for the man’s proton beam therapy, citing a policy that excluded the treatment as “not medically necessary” and “experimental or investigational.”

The lawsuit argues that proton beam therapy has been proven to be a successful and preferable treatment option in cases such as the plaintiff’s, whereas less precise photon beam therapy could damage healthy cells surrounding the tumor site.

“Indeed, for those in [the plaintiff’s] position who have been prescribed Proton Beam Therapy, this type of radiation is the only kind that could not only help cure their cancer, but also significantly limit radiation exposure and resulting damage to surrounding healthy cells, tissues, or organs,” the complaint reads.

Aetna has nevertheless refused to cover this treatment based on its “uniform application of an arbitrary medical policy,” the case says. The plaintiff points out that proton beam therapy is more expensive than more traditional radiation, and claims Aetna has excluded it from covered options based solely on the higher cost. The man says he has spent approximately $50,000 out-of-pocket for his treatment—which, according to the case, has been successful and produced no discernible radiation side effects—and now seeks to change Aetna’s policy for the benefit of proposed class members. From the complaint:

“[The plaintiff] now pursues this fight for change, individually and on behalf of the Class Members, particularly those less fortunate and unable to bear the economic expense of Proton Beam Therapy treatment, so that Aetna’s insured members suffering with cancer can focus on their recovery rather than on the extreme and outrageous anxiety and distress of wrongful coverage denials and the crippling cost of care.”