Did your insurance company deny coverage for Harvoni, a new cure for hepatitis C, because your disease was not advanced enough?
Harvoni is a hepatitis C drug made by Gilead Sciences. It has been on the market since October 2014, cures more than 90% of people with hepatitis C in as little as eight weeks, and has far fewer side effects than other treatments.
What is the problem?
Cost. The standard 12-week course of Harvoni costs over $90,000, or about $1,000 per pill. Harvoni is cheaper than a liver transplant, but still very expensive. Many health insurance companies have denied claims from patients who are in the early stages of hepatitis C, claiming treatment is not “medically necessary.” The problem is that by the time Harvoni is medically necessary, a patient may be extremely sick.
Harvoni Insurance Claim Denial Lawsuit
June 2015 — The Los Angeles Daily News reports that a lawsuit (PDF) has been filed against Anthem Blue Cross by a woman with hepatitis C who was denied coverage for Harvoni.
The woman, Shima Andre, is 42 years old and was diagnosed with hepatitis C in 2011. She is still in the early stages of the disease, but suffers from symptoms like fatigue, sharp pains, skin-color changes, and a benign tumor on her liver. Every six months, she must undergo ultrasounds of her liver and viral load counts.
When her doctor prescribed Harvoni in October 2014, she received a letter from Anthem Blue Cross denying coverage because it was “not medically necessary” until she has reached Stage 3 or Stage 4 of the disease. Multiple appeals by her doctor were denied.
By the time she reaches Stage 3, she will have cirrhosis (permanent scarring) and may be too fatigued to work. Her attorneys accuse Anthem Blue Cross of acting in “bad faith” by failing to provide coverage and breaching its contractual obligations to patients.
According to the lawsuit:
“Blue Cross prefers that its insureds get much worse before paying for treatment almost guaranteed to cure their disease. The health of Shima and her family are of no concern to Blue Cross in the face of Blue Cross’s profits.”
The case is Andre v. Blue Cross of California et al., Case No: BC582063, in the Superior Court of the State of California, County of Los Angeles.
What is Hepatitis C?
Hepatitis C is a liver disease caused by a contagious virus that spreads in blood. About 3 million people in the United States have chronic hepatitis C infection and 15,000 die from liver disease linked to the infection every year.
Symptoms of liver disease from hepatitis C can take years or even decades to appear. About 5-20% of people infected with the virus will develop cirrhosis, scarring of the liver that results from widespread fibrosis (liver cell damage).
By the time hepatitis C has progressed to cirrhosis (scarring of the liver), the patient is at risk of dying from life-threatening complications unless they receive a transplant or are cured with a drug like Harvoni.
Complications of Hepatitis C
- Severe liver damage
- Liver cancer
- Internal bleeding
- Ascites (fluid in the abdomen)
- Encephalopathy (brain damage)
- Jaundice (yellowing of the skin and eyes)
- Chronic fatigue