Aetna to Pay $25.5 Million in Damages for Denying Late Cancer Patient’s Claim

by Sokolove Law

For “recklessly” disregarding their duty to deal fairly and in good faith, health insurance giant Aetna has been ordered to pay $25.5 million to the estate of a late cancer patient and her family.

In a stunning rebuke of the way Aetna does business, the jury voted 9-3 to award $15.5 Million in compensatory damages and another $10 Million in punitive damages. Two of the dissenting jurors reportedly wanted the punitive damages to be higher. The verdict, the largest of its kind in the state of Oklahoma, sent a clear message to Aetna, who is already under investigation by several other states for irresponsibly reviewing and denying allegedly valid claims.

At issue in the Oklahoma case is Aetna’s denial of a cancer treatment known as proton beam therapy. The doctors recommended this course of action because the patient’s cancer was located in close proximity to the brainstem. Along with other side effects, traditional radiation treatment could have blinded the patient, but Aetna did not budge and denied the claim. After listening to the testimonies of the medical directors responsible for reviewing the patient’s claim, jurors decided that Aetna failed in their duties.

Aetna Misses Their Own Mark

In the mission statement of the company, the nation’s third-largest insurance provider, Aetna claims that “the people we serve drive every decision we make.” More than 23 million customers rely on Aetna to live up to that promise. When the company’s actions fail to put patients first, the results are sometimes fatal.

In the Oklahoma trial, the jury was stunned to learn that Aetna medical directors had spent mere minutes reviewing the case and appalled to find out that this was normal practice for the company. Some medical directors may review up to 80 cases a day, if they read them at all, leaving scant time to make life or death decisions.

To the jury, the review system seemed geared toward what Aetna wanted, not what the patient needed. Aetna’s medical directors denied the proton beam therapy on the grounds that it was “investigational and experimental.” The fact is, proton beam therapy has been around for decades, and oncologists were recommending this specific treatment for the safety of the patient. Wasn’t patient safety supposed to be a priority for Aetna?

Jury Sends Message to Healthcare Industry

The behavior Aetna deemed appropriate behind closed doors looked much different in the light of a courtroom. The jury saw the actions of the medical directors as plainly reckless and sent a message to Aetna and the entire healthcare industry: stop putting profits ahead of patients.

After all, Aetna is an extraordinarily profitable company. The jury was told Aetna averaged $3.5 Million in profit each day. To many, it seems inappropriate that Aetna should take such good care of their shareholders only to deny critical coverage to a suffering cancer patient.

Or, consider this: Aetna’s CEO Mark Bertolini walked away with more than $41 Million in compensation in 2016. That amount is more than if Mr. Bertolini received a Tulsa police officer’s total yearly salary, every day of the year. Tulsa is the most dangerous city in Oklahoma, and one of the most dangerous in the country.

For the commonsense American, perhaps the most shocking aspect of the case is that Aetna believed they were in the right and even applauded the decisions made by their medical directors. It’s difficult to fathom how Aetna squares this outlook with a professed desire to let patients’ needs drive their decision-making.

What Are the Implications of This Verdict?

It is too soon to characterize this as a landmark ruling, but a verdict of this size will be felt throughout the industry. Some light has been shed on Aetna’s inner-workings, and it is hard to imagine that other insurers are not engaged in similar bad faith practices.

Ideally the verdict will help shift power back into the hands of patients and their physicians. Health insurance companies have an important role to play, but in the current climate, they are too easily able to override the needs of patients and families if they deem the bill is too high. In short, there is much to suspect about health insurance providers who are highly-profitable, non-transparent, and unable to foot the bill for necessary procedures.

Typically, individuals have no means to know whether or not their insurers are acting in good faith and fair dealing. Americans have to be able to trust those who insure them. The entire system is predicated on it. To see Aetna condone such “reckless” behavior is a scary moment, but we can hope it is a turning point for a system in need of change.

Aetna to Pay $25.5 Million in Damages for Denying Late Cancer Patient’s Claim was last modified: November 15th, 2018 by Sokolove Law