UnitedHealthcare has agreed to pay more than $9 million to settle a class-action lawsuit alleging that the insurer wrongfully denied coverage for proton beam therapy, a type of specialized cancer treatment.
According to court documents filed May 9, the insurer will pay up to $75,000 to members in employer-sponsored plans diagnosed with prostate, primary-central nervous system or cervical cancer who had claims for proton beam therapy denied, and paid for the treatment out-of-pocket.
The total payments to members will be capped at $6.75 million, according to the document. UnitedHealthcare will also pay $2 million in attorneys fees and awards to lead plaintiffs in the case. The insurer could pay an additional $500,000 in fees.
UnitedHealthcare will also change its coverage policies for proton beam therapy as part of the agreement, a move the plaintiffs say will make it easier for members to have requests for the therapy approved. As part of the change, UnitedHealthcare will eliminate a list of 13 diagnoses for which proton beam therapy was considered “unproven and not medically necessary,” according to agreement.
The class-action lawsuit was brought by three UnitedHealthcare members in different employer-sponsored plans in 2019, and consolidated in the U.S. District Court for the District of Massachusetts. The plaintiffs alleged that UnitedHealthcare wrongfully classified proton beam therapy as experimental, forcing them to pay out-of-pocket for the treatment.
Proton beam therapy is an alternative to traditional radiation therapy, and is particularly effective in treating tumors close to critical organs, according to the National Association for Proton Therapy. The treatment makes up less than 1% of radiation therapy in the U.S.
There are 90 individuals who submitted post-service claims for proton beam therapy to UnitedHealthcare and 150 who had prior authorization requests denied who will receive a notice of the settlement, according to the agreement.
UnitedHealthcare does not admit any wrongdoing as part of the settlement, and reached the settlement to avoid “the burden, expense, risk and uncertainty” of continuing litigation.
Becker’s has reached out to UnitedHealthcare for comment and will update this article if more information becomes available.
