Serving Up Justice 💼

Hannah Wolf  0:03  
Welcome to Healthcare Policy pop. I'm Hannah Wolf. It's Tuesday, December 5 2023. Today's pop topics an insurance company told a man with cancer that his treated wasn't quote, medically necessary, but he happened to be a trial lawyer and had the time, resources and experience to fight back. Robert Salim was diagnosed with stage four throat cancer in 2018. And his doctor recommended proton therapy as the best treatment route.

Robert Salim  0:35  
What I recommend is that you do proton therapy because where the tumor is located, we're going to have to do tons of collateral damage if we use regular radiation. So I said, that's great. Let's do it. He called me two days later and said Blue Cross Blue Shield says proton radiation is experimental and they won't approve it.

Hannah Wolf  0:58  
Yes, you heard that right. Insurance told him the procedure wasn't medically necessary. On that day Salim was a patient but for the past several decades, he's also been a lawyer and a really good one. He was named one of the 100 best trial lawyers in the country. So what it seemed do what he does best, he fought back.

Robert Salim  1:21  
Yeah, back home to my law office. And I said, this is BS. So we filed suit. In court, they're in my hometown in Louisiana. We got removed because my group health plan was an ERISA plan. So we got removed a federal court in Alexandria, and started to litigation.

Hannah Wolf  1:42  
Of course, while getting denial after denial, the cancer continued to grow. So Salim did what he had to do and what most patients are not able to do. He paid the $96,000 out of pocket to get the proton therapy. 

Robert Salim  1:59  
We started and we did 60 rounds in three and a half months and with 10 rounds of chemo. In the meantime, we kept appealing it to the fifth set. And once again, all the time that denied it. 

Hannah Wolf  2:14  
Salim said although he was upset that insurance denied it, he was far from shocked. I've

Robert Salim  2:21  
I've been a personal injury lawyer for 47 years and at the time, 42 years, I was very aware of insurance companies and built my career over litigating against them, seeing them be arbitrary and capricious so many times I have dealt with it. So to be honest with you, I was not surprised.

Hannah Wolf  2:43  
So what can we do to make sure patients aren't getting denied their life saving treatments? Salim says it will take good old outrage just like it did with insulin.

Robert Salim  2:54  
And maybe they'll reach out and say enough's enough. But why is insulin $200 in the US and $10 in the rest of the world? Can anybody explain that to me? The argument is we need to make profits to develop new drugs, right? Great. make a profit. It $35 You're still making $34 Do you need to make $219? No, but everyone knows what the problem is. Congress knows what the problem is, but they won't get off their duff and address the problem. 

Hannah Wolf  3:30  
You can hear more from Saleem in the latest patients rising podcast episode, you can find that link in the show notes.

Hannah Wolf  3:42  
Speaking of insulin, the Arizona Attorney General is suing insulin manufacturers and PBMs for allegedly inflating the price of insulin and keeping excess profits. The lawsuit is seeking civil penalties from three PBMs CVS Caremark, Express Scripts, and optim RX. Arizona Attorney General Chris Mays said quote, despite promises to pass along the increased rebates to health insurers and patients, the PBMs instead use the complex financial and business structures to keep a large part of the inflated profits for themselves. You can read the full story by using the link in the show notes. That's all for today. We're back on Thursday for another health care policy pop a resource of patients rising now. I'm Hannah Wolf, have a great day.