My friend has a chronic illness and has been on a specific medication for over a decade that kept his disease under control. This treatment allowed him to live a relatively healthy life. About 18 months ago, his insurance suddenly stopped covering the medication, insisting he try cheaper alternatives.
Here’s the issue: once someone stops this particular drug, its effectiveness drops if restarted. Unfortunately, the cheaper options didn’t work, and his symptoms flared up badly. They tried putting him back on the original drug, but as expected, it no longer works. He’s now lost 30 pounds and is scared for his health and future.
Is there anything he and his family can do to hold the insurer accountable for this decision? Does he have any legal or regulatory recourse? This feels like negligence on the insurer’s part, and it has severely impacted his health.
This is such a tough situation. While it might not be illegal, it’s worth looking into the fine print of the policy to see if there’s any way the insurer breached their obligations. You could also contact a lawyer who specializes in health insurance disputes to explore options. It might not reverse the situation, but it could help bring some accountability.
Sadly, many insurers have clauses that protect them from liability in cases like this. However, creating public pressure through media or advocacy groups might help. You could try reaching out to local news or organizations that handle healthcare issues to bring attention to the situation.
Consider contacting investigative journalists or organizations that focus on healthcare injustices. ProPublica, for instance, has reported on similar cases and might help highlight the story.
Since the medical community knows stopping this drug can cause long-term harm, your friend may have grounds to file an appeal with the insurer. The appeal should cite medical evidence showing why their decision was harmful. If the insurer denied without considering this, they might be forced to revisit the case.
If this is a biologic drug, insurers are notorious for trying to cut costs with these expensive treatments. Unfortunately, appeals often fail unless there’s strong advocacy from a doctor. It might be worth getting an attorney or patient advocate involved to push harder, though the chances of reversing the damage are slim at this point.
Your friend should file a complaint with the state’s department of insurance or health services. These agencies oversee insurers and might be able to investigate whether the denial was justified or in line with regulations.