In a case with potentially national ramifications, Blue Cross &
Blue Shield of Michigan has agreed to pay for high-dose chemotherapy
with bone marrow or peripheral blood stem cell transplant support for
cancer patients who were formerly denied coverage.
Lisa Gleicher, the Detroit attorney who litigated the case, called
the settlement a "victory for consumers, who too often are the
ones who get overlooked in this big, big business of health care."
Ms. Gleicher represented more than 120 people, most of them in a
class action suit heard in Wayne County Circuit Court, in an effort
to get Blue Cross to broaden its coverage for persons needing
high-dose chemotherapy/stem cell transplant for breast cancer. The
insurance company previously limited coverage to just a few specified
types of cancer.
Ms. Gleichers involvement with cases of this type goes back to
about 1990. At that time, she said, Blue Cross was routinely denying
coverage of high-dose chemotherapy for women with breast cancer,
contending that the treatment was "experimental" and
"investigational." About a dozen women asked her to
represent them, and she filed a class action suit on their behalf. In
the summer of 1992, before the case came to trial, Blue Cross settled
out of court after losing a similar case that was tried in
Michigans Upper Peninsula.
"We thought we had scored an important victory," Ms.
Gleicher said. "But unbeknownst to us, Blue Cross approached the
Michigan Insurance Bureau to change the language of what they
covered. They added riders to everybodys policies, including
one called Rider BMT, that excluded coverage of high-dose
chemotherapy for all but five diseases. And because the only people
the Insurance Bureau ever talks to are from insurance companies, they
let them get away with it. Pretty soon I started getting calls again.
For a while, I didnt know what to do. I felt like I had won the
battle but lost the war."
Ms. Gleicher is nothing if not persistent, however, and decided to
keep fighting. After considering alternatives, including basing the
suit on constitutional grounds, she ran across a Michigan statute
that had been on the books since 1989, but which nobody seemed to be
taking into account.
It stated simply that insurance companies were required to cover
high-dose chemotherapy for cancer if the therapy met five
straightforward criteria. Transplants were included in the coverage
as necessary adjuncts to the chemotherapy.
She filed the class action suit in a Michigan circuit court in
February 1996. At the same time, she also represented about two dozen
people in individual cases in federal court because their insurance
benefits were covered by federal statutes.
Blue Cross Settles
Both the federal and circuit court judges ruled that the law required
coverage, Ms. Gleicher said. After losing the first few cases in
federal court, Blue Cross & Blue Shield saw the writing on the
wall. The insurer settled the class action suit and the remaining
federal cases in August 1997, agreeing to pay for complete coverage
for all of Ms. Gleichers clients (see box for some of her
clients comments on the victory).
The Clients Reactions
Eva Navarro, whose court victory resulted in coverage for a stem cell
The settlement is important, she noted, because Blue Cross & Blue
Shield often sets the standard for medical coverage--not just in
Michigan, where it accounts for more than 50% of commercial health
insurance, but in the rest of the country as well.
Blues Should be Commended
William Peters, MD, president of the Barbara Ann Karmanos Cancer
Institute in Detroit, called the settlement an important advance.
"Blue Cross should be commended. This will benefit patients for
years to come," he said.
Said Ms. Gleicher: "Everyone in Michigan will follow the Blues
and expand their coverage for high-dose chemotherapy and related
transplants. Theyll have to if they want to compete in this
market. What Id like to see now is federal legislation,
possibly modeled on these propatient Michigan laws, that says these
are no longer investigational procedures, but the
acknowledged standard of care. That would be a real victory for consumers."
Reprinted, with permission, from the April 1998 issue of the Blood
& Marrow Transplant Newsletter, 1985 Spruce Ave., Highland
Park, IL 60035. The newsletter may be contacted by phone at
847-831-1913; fax: 847-831-1943; or e-mail: firstname.lastname@example.org.
The website address is http://www.bmtnews.org.