Attorney General Cuomo Secures Health Insurance Coverage For Breast Cancer Patient's Life-saving Diagnostic Test And Treatments After Repeated Denials

SYRACUSE, N.Y. (December 23, 2008) – Attorney General Andrew M. Cuomo today announced that his office has secured full health insurance coverage for a Central New York breast cancer patient’s life-saving diagnostic test and treatments after they had been repeatedly denied.

Christine Langlois of Onondaga County learned that she had suffered a recurrence of breast cancer in late 2006. Her claim for a doctor ordered Positron Emission Tomography (PET) scan was denied by her health insurer, Excellus, as was an appeal to the state Insurance Department.  Additionally, her subsequent radiation treatments were likewise denied. She then told her story during the Health Care breakout session at the Attorney General’s Community Forum at the State Fairgrounds in November. Once Attorney General Cuomo heard about her situation, he directed his Health Care Bureau to contact the company and was able to reverse the decision.

“This is how government is supposed to work – a state agency coming into a community to hear local concerns, responding to those concerns, and getting positive results,” said Attorney General Cuomo. “Excellus did the right thing by responding to my office and agreeing to cover this life-saving test and treatments. I strongly encourage any New Yorker who is having an issue with a health insurance company to contact my office.”

Langlois was originally diagnosed with Breast Cancer in 1997.  In late 2006, a follow-up blood test revealed that she had a rising tumor marker - which meant that there was a recurrence of the cancer.   Unfortunately, the blood test alone was not enough to specifically locate where the cancer had recurred.    Langlois' doctor contacted her insurance company, Excellus, for prior approval for a PET scan.  Her doctor was told that prior approval was not necessary.  In December 2006, since her doctor was certain that the cancer had returned, he ordered the PET scan.  The PET scan was able to pinpoint the location of the cancer.

In the Spring of 2007, pursuant to the terms of her insurance contract, Excellus performed a retrospective review and determined that the PET scan was not medically necessary.  According to her insurance contract, a PET scan can only be used after other imaging techniques were actually done and then proved to be inconclusive.  Consequently, insurance coverage for the PET scan was denied leaving Langlois with a more than $4000 bill. 

Langlois immediately filed an internal appeal with Excellus, which upheld the denial based on the language of her insurance policy.   Langlois then filed an external appeal through the New York State Insurance Department.  That appeal was also unsuccessful.

Langlois began radiation treatments in the Summer of 2008. Insurance coverage for those treatments was likewise denied as a result of another retrospective review. Now, Langlois was looking at bills in excess of $20,000.

In her final attempt for help with this seemingly insurmountable problem, Langlois attended Attorney General Cuomo's Community Forum on November 19, 2008 at the New York State Fairgrounds in Syracuse.  During the Health Care breakout session, Langlois clearly described her problems to the Attorney General's staff.  She was immediately put in touch with the Attorney General's Health Care Bureau which began working on her problem. 

After reviewing the documents, the Attorney General's office contacted Excellus and provided them with several reasons for the company to revisit and reverse its decision denying coverage for the PET scan. On December 10, 2008, Excellus agreed to reverse its denial of coverage for the PET scan and all of her radiation treatments.

Langlois was informed of Excellus' decision to cover the costs on her birthday, to which she said, "That is the best birthday present I could receive today."   

The Attorney General’s Health Care Bureau helps consumers navigate the complex health care system, challenges insurers who won’t cover provided costs, and targets organizations that have fraudulent, misleading or deceptive practices. The bureau also reaches out to New Yorkers to ensure they know their health care rights. Consumers who believe they may have been treated unfairly by a health care provider, HMO or insurance plan should call the Attorney General’s Health Care Bureau's Helpline at 1-800-428-9071.

The matter was handled by Timothy A. Clune, Chief of Attorney General Cuomo’s Health Care Bureau.

 

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