UnitedHealthcare is the largest insurer of health benefits in the United States but despite its vast reach and revenue, UnitedHealthcare is refusing to approve health benefits for its own employee’s family. Jonathan Mischo is a young father and husband of a UnitedHealthcare employee who has battled multiple sclerosis (“MS”) for several years. MS is a chronic disease affecting the central nervous system (brain and spinal cord) and has no cure.
Mr. Mischo is battling UnitedHealthcare’s arbitrary denial of lifesaving infusions to treat MS. Mr. Mischo explained that “MS changed my life and made every day a challenge to do even the basic things that I always took for granted. With proper treatment, I was able to at least regain some sense of self-reliance and enjoyment of life. United's denial has taken that away from me again and made it difficult to even take care of myself, much less my family."
Mr. Mischo has received treatment at the University of California San Francisco Multiple Sclerosis Center (“UCSF”) since his diagnosis. Treatment has been a challenge. He attempted treatment with an oral medication Tecfidera but suffered a severe allergic reaction. He attempted treatment with infusions of Tysabri but had frequent infusion reactions which left him debilitated for weeks after each infusion.
Mr. Mischo finally obtained positive results with Rituxan infusions. Blue Shield of California and UnitedHealthcare approved Rituxan for Mr. Mischo for years. Mr. Mischo receives health benefits through his wife’s employment with UnitedHealthcare.
When a new MS drug, Ocrevus, was approved in 2018 by the FDA, Mr. Mischo attempted to switch from Rituxan to Ocrevus, with United’s approval. He suffered severe infusion reactions with Ocrevus, including a reaction which put him in the emergency room and an EKG that demonstrated a possible heart attack.
Following these experiences, Mr. Mischo returned to treatment with Rituxan – with the approval of UnitedHealthcare – and safely managed the all-day infusions with careful adjustment of pre-medications and infusion rate. UnitedHealthcare’s approval suddenly ceased in October 2021 when it denied further benefits for Rituxan claiming Mr. Mischo did not “try Truxima or Ruxience,” Rituxan biosimilars.
Mr. Mischo’s neurologist, Dr. Ari Green, Director of the UCSF Multiple Sclerosis Center, explained to UnitedHealthcare that Mr. Mischo had a history of infusion reactions, including a reaction which put him in the emergency room. While the biosimilars Ruxience and Truxima have a similar mechanism and general structure, they are not the same molecule as Rituxan and expose Mr. Mischo to the risk for new infusion reactions that have the potential to be very serious for Mr. Mischo who has a history of adverse reactions.
Dr. Green advised against Mr. Mischo attempting infusions with Truxima or Ruxience because of the “unnecessary risk for severe infusion reactions and further delay of care.”
UnitedHealthcare inexplicably ignored the opinion of Dr. Green and refused approval of Rituxan.
Now Mr. Mischo faces the risk of MS relapse or disease progression due to UnitedHealthcare’s refusal. Dr. Green has stated that further delay of proper treatment may leave Mr. Mischo with permanent disabilities and cause irreparable harm.
Mr. Mischo has retained the law firm Kantor & Kantor LLP which has filed a lawsuit against UnitedHealthcare, but it may be too late to avoid progression of the disease. Mr. Mischo has experienced an increase in MS fatigue which he says has “gotten so bad that I simply can’t function most days” and he misses spending time with his young son and wife.
UnitedHealthcare refuses to acknowledge the pain it has inflicted on one of its own employee’s spouses by its arbitrary denials. Mr. Mischo deserves better. He deserves this lifesaving medication.
“This case is one that should never have to happen. UnitedHealthcare could have easily prevented Mr. Mischo’s unnecessary suffering. A person’s life is at stake. I was more than happy to step in and represent his interests because UnitedHealthcare chose not to,” said Elizabeth K. Green, partner attorney at Kantor & Kantor. Ms. Green specializes in representing patients who have been denied health benefits.