If you read about Orrana Cunningham, and the story is all over media, Orrana Cunningham passed away in 2015. November, 2018, her family was awarded $25.5 million by an Oklahoma County District Court to be collected from Aetna for reckless disregard, as stated in the reports, for denying coverage for the recommended treatment for her illness as "experimental and investigational." She didn't get the treatment. Naturally, Aetna is considering appeal.
Yet there's a great deal of thanks owed to the Cunningham family for bringing the lawsuit and pinpointing several strong criteria for battling with your insurer when it comes to denial of coverage.
First, follow the appeals process delineated in your insurance contract.
Second, when making that appeal, note whether the 'experimental and investigational' treatment IS covered in other instances, indicating it's actually NOT experimental and investigational. Orrana's recommended treatment was. It is covered for pediatric cases and for Medicare patients.
Further, the FDA approved the therapy she needed.
Next, hold the in-house doctors' feet to the fire. In this case, inadequate review of the case was also evident from Aetna doctors complaining about how many cases they have to review each day and evidence that the life and death decision of whether to grant the appeal was made by Aetna docs in about 30 minutes.
Aetna was accused of denying coverage for profit reasons, having physicians unqualified to make the decisions who were also 'overworked' and noted that Aetna awards profit-based bonuses.
After the denial, the family did obtain necessary funds by mortgaging their home and establishing a GoFundMe page. Orrana herself began the fight that her family finished on her behalf.
