DBJ secured a permanent injunction in Jackson County Circuit Court against an HMO that denied a Kansas City woman an “experimental” treatment.
Karen Moses needed a gastric stimulator after her body rejected a pancreas transplant. Her health plan denied coverage for the treatment as “experimental,” despite a letter from her doctor, the leading expert in the field. “The credentials of the treating doctor were so impressive,” said attorney Scott S. Bethune of DBJ, who handled the case without charging a fee. “He was in fact an expert in this area.”
The court found that “while it is reasonable and necessary for an insurer to have an experimental exclusion so members do not have to pay for procedures which are purely experimental or requested by a scientist stirring a magic potion in some laboratory at the top of a mountain with lightning flashing about, it was clear and beyond dispute that the requested procedure had been standard treatment, and indeed the only treatment available for patients with the discussed medical condition.”
In denying coverage, the HMO actually attempted to rely on two articles written by Moses’ doctor himself. In ruling against the HMO, the court noted that other insurers provide coverage for the exact procedure requested in this case.
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