A jury in a state court in Oklahoma City has awarded a $26 million verdict to the plaintiff in a case involving denial of coverage for proton beam therapy for squamous carcinoma of the throat.
The jury awarded the damages, in the District Court for Oklahoma County, in connection with a finding that the insurer had recklessly disregarded its duty to deal fairly and in good faith with the Cunninghams, according to lawyers for the plaintiffs.
The plaintiffs in the case are Ron Cunningham and the estate of Ron Cunningham’s wife, Orrana Cunningham. Orrana Cunningham died in 2015.
In 2014, Cunningham, who was a firefighter, and his wife had health coverage from a unit of Aetna Inc., provided through the Oklahoma City Firefighters Health and Welfare Trust VEBA. The plan did not cover experimental treatments.
In November 2014, a doctor told Orrana Cunningham that she had throat cancer. The doctor recommended that the cancer be treated with proton beam therapy.
Aetna denied the claim in December 2014, contending that, for purposes of treating squamous carcinoma of the throat, proton beam therapy was still an experimental treatment.
Cunningham filed an appeal.
Aetna denied Cunningham’s first appeal in January 2015. IPRO, an outside review organization, denied Cunningham’s claim in February 2015. Aetna issued its own final coverage denial in February 2015.
The Cunninghams mortgaged their home to come up with the $90,000 needed to pay for proton beam therapy out of pocket.
The Cunninghams filed a lawsuit against Aetna in May 2015.
The Employee Retirement Income Security Act of 1974 puts tight restrictions on the damages plaintiffs can get in lawsuits against benefit plans governed by ERISA. Because the Oklahoma City firefighters’ plan was a government employer plan, not a plan provided by a commercial employer, the plan was not subject to ERISA.