Group Sues 5 HMOs for Cancer Therapy

PacifiCare Health Systems Inc. and Health Net Inc. are among five health maintenance organizations named Wednesday in a lawsuit claiming the insurers are unlawfully denying coverage for proton beam radiation therapy to treat prostate cancer.

Cancer Victims for Quality Healthcare, a nonprofit group, filed the suit in Los Angeles County Superior Court to force the insurers to cover the therapy. The suit seeks class-action status, said plaintiffs’ lawyer Michael Bidart of Claremont.

If the lawsuit succeeds, the five HMOs would have to cover the treatment, which costs between $35,000 to $50,000.

The complaint was filed under the state’s unfair business practices law and seeks a court order to stop the HMOs from denying coverage of the treatment. It does not seek monetary damages aside from legal fees and restitution to class-action members who have paid for the treatment.

The defendants are engaging in “a fraudulent scheme with the ultimate goal of shifting the burden of the plan member’s health care from the HMO back to the plan member,” the complaint said.

Health Net spokesman David Olson said it has been three years since the Woodland Hills-based company last denied a patient coverage for the proton-beam treatment. The company now approves coverage for all patients whose doctors have recommended the therapy, Olson said.

Blue Shield of California, Kaiser Health Plan Inc. and Cigna Corp. also were named as defendants. None of the firms returned calls for comment.

The HMOs allegedly told patients that proton beam therapy, which shoots radiation at the tumor, is an experimental therapy and not covered under their policies, according to the complaint.

Blue Cross, a division of Wellpoint Health Networks, and Aetna Inc. cover the treatment, Bidart said.

The American Cancer Society estimates about 180,000 U.S. men are diagnosed with prostate cancer each year and about 37,000 will die from the disease.

Class-action members must be California men enrolled in the defendants’ health plans who were denied proton beam therapy.