Turn to Kantor & Kantor if Your Proton Therapy Claim Was Denied
California Proton Therapy Denial Lawyers
Proton beam therapy has gained recognition as an effective cancer treatment, yet too many patients find their proton therapy claim gets denied. Sadly, perhaps you are among those cancer patients. When your health is at stake, you want the best treatment available. That’s why you should turn to our California proton therapy denial lawyers for help.
If you have cancer, working closely with your doctor is crucial to determine the most suitable treatment plan. If your doctor recommends proton beam therapy as a treatment option for your cancer, it is because it offers an effective approach to eliminating or reducing tumor growth. Proton therapy may be your best possible treatment given the location and type of tumor you have. It can also save your life. Yet, your insurance company may deny your claim.
If you face a denial of a proton beam therapy claim, don’t wait to seek legal help. When you are a cancer patient, every moment is precious.
Rely upon our highly skilled and experienced proton therapy denial lawyers at Kantor & Kantor. Get your free, 30-minute consultation now. Call us at 818-886-2525 to discuss your case.
Why Do Insurance Companies Deny Proton Beam Therapy Claims?
Insurance companies are for-profit businesses and, as such, their first concern is their bottom line. While proton beam therapy offers promising results, it may come at a higher cost than standard radiation therapy. Despite its proven efficacy, many insurance companies deny coverage for proton therapy, posing a challenge for patients seeking this advanced treatment. As a policyholder, you trust insurance companies to fulfill their obligations when you need them. Regrettably, insurers don’t always act in good faith and may fail to meet their legal duties.
Insurance companies often classify proton beam therapy as experimental or investigational, establishing policies that result in automatic denials of coverage. This rigid approach overlooks the unique circumstances of individual patients and dismisses their specific needs. Such blanket denials can have severe consequences for patients who rely on this therapy to fight cancer. Courts have recognized this as a clear example of insurance bad faith, and plaintiff awards in these cases can be in the millions. When an insurer unfairly denies, underpays, or delays payment of a claim, it acts in bad faith.
If your insurance company denies your proton beam therapy coverage, you can fight for your benefits with the help of an experienced attorney.
Trust in Our Experience to Provide the Legal Guidance You Need
Kantor & Kantor, LLP is a trusted law firm with over 20 years of expertise fighting health insurance claim denials. Our California proton therapy denial lawyers know tactics insurance companies use to deny claims. We understand the importance of receiving the appropriate care and coverage when you’re a cancer patient. We will advocate for the coverage that is rightfully yours.
Legal battles involving insurance claim denials for proton therapy treatment are often highly complex. Find out how we can fight for you. Call 818-886-2525 for your free, 30-minute consultation with one of our California proton therapy denial lawyers.
Why Choose a Proton Therapy Lawyer at Kantor & Kantor?
Being diagnosed with cancer can leave you mentally and emotionally drained. If your insurance company denies your claim, it hinders you from getting the right treatment for your cancer. This leaves you and your loved one in a dangerous and scary position. Hiring the best lawyer for your case is imperative.
Choosing the right California proton therapy denial lawyer is the key to maximizing your chances of a successful outcome. Kantor & Kantor is a highly reputable law firm focusing on insurance law, including health insurance bad faith claims. Here are compelling reasons to consider our attorneys at Kantor & Kantor for your proton beam therapy bad faith claims case:
- Experience and a Winning Record: We have over two decades of legal experience and a proven track record in fighting unjust insurance claim denials, including winning proton beam therapy cases. Our California proton therapy lawyers possess in-depth knowledge of insurance law, including the specific challenges and nuances related to proton beam therapy claims.
- Client-Centered Approach: Insurance companies treat you like a file number, but at Kantor & Kantor, our team treats you like a person. Our compassionate attorneys understand the challenges you face and the stress a cancer diagnosis places upon you and your loved ones.
- Detailed Attention to Your Needs: Each case is different, and we take a personalized approach to every client. We understand the emotional and financial toll insurance bad faith can have on individuals and their families. We will listen to your story, evaluate the details of your claim, and develop a tailored legal strategy that aligns with your goals. We prioritize communication and ensure you are informed and involved throughout the legal process.
- We Aren’t Afraid to Go to Court. Instead, we are the firm that insurance companies fear. We prepare every case as if we will go to trial. Our strong litigating skills often lead to victories in court. When insurers work with law firms that they know will settle to avoid a court battle, they will offer a lowball settlement amount. When they face attorneys from Kantor & Kantor, they know that an expensive legal battle over a proton therapy denial may be ahead. Rather than pay the high cost of a trial award, the insurance company will offer more in a settlement when you’re represented by our team instead of another law firm.
- Strong Reputation: We have a strong reputation for our commitment to fighting for our client’s rights. Ask a judge, our fellow attorneys, or mediators who they recommend for a health insurance denial case. We are confident that they will say Kantor & Kantor. Our reputation for fighting insurance companies speaks to our dedication and effectiveness in representing our clients’ best interests.
Our proton therapy denial lawyers are available to answer your questions, address your concerns, and guide you through the entire process with care and compassion.
Is Proton Therapy Covered by Insurance?
Every insurance company’s policy coverage is different. This is because they establish guidelines for evaluating coverage requests. When it comes to proton therapy, insurers sometimes have clinical guidelines that are outdated or not based on current standards of medical care.
Insurance companies do not universally provide coverage for proton therapy to all individuals. Sometimes, you have to fight for it.
Eligibility for proton therapy treatment is typically limited to cases where the tumor is located near important organs, such as the lungs, neck, brain, head, heart, gastrointestinal tract, or spine. Even if a patient meets the necessary qualifications, there is still a possibility that an insurance company may deny a proton therapy claim.
Why is Proton Therapy Not Covered by Insurance?
How to Fight a Proton Therapy Insurance Denial
If your insurance company denies coverage for proton beam therapy, you can challenge their decision through appeals. You may be led to believe proton therapy is not covered by your insurance and wonder why. The insurance company may use the term “request for review” of your denial instead of “appeal,” but the latter term is more commonly used by most people, so we will use it here. Engaging the services of an experienced California proton therapy denial lawyer can significantly enhance your chances of building a compelling case and successfully navigating the appeals process.
Here are some steps you can take during the appeals process:
1. Know the Details of Your Health Insurance Policy
Before initiating the appeals process, it is important to understand your insurance policy comprehensively and the requirements for challenging the insurer’s decision.
Begin by familiarizing yourself with your specific type of health insurance plan, such as a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO). Additionally, ascertain the reason for the insurance company’s refusal to cover proton therapy as stated in the denial notification. This information will be the foundation for your appeal. Furthermore, gather information regarding the insurer’s unique appeals process and the steps you must take to challenge their decision. Being well-informed will greatly enhance your ability to navigate the appeals process effectively.
Our team at Kantor & Kantor knows that you may feel overwhelmed in trying to understand all the information in your health insurance policy. Trust our California proton therapy lawyers to understand what your policy will cover and build a strong legal case.
We’ll address all of the legal matters so you can focus on fighting your cancer and spending time with your loved ones.
2. Get a “Letter of Medical Necessity”
To effectively navigate the appeals process and increase your chances of obtaining coverage for proton therapy, explore your options and engage knowledgeable medical professionals about endorsing this treatment. Finding an oncologist with expertise in proton beam therapy is essential.
If your insurance company denies coverage based on the claim that proton therapy is not medically unnecessary, you can request a “Letter of Medical Necessity” from your doctor. This statement can significantly strengthen your case and persuade insurers of the essential nature of this treatment. This letter should comprehensively explain proton therapy and should highlight why your doctor recommended it as the preferred procedure over alternative options, such as typical radiation treatment or other treatment that could pose more risk.
Our proton therapy lawyers know what strategies work to successfully explain why this treatment is necessary. We can provide guidance regarding the content of your letter. This documentation may even be central to a lawsuit if your proton therapy denial case goes to court.
3. Gather Documentation to Support Your Appeal
To strengthen your position before commencing the appeals process, it is crucial to gather all relevant documentation that can provide substantial support for your case.
This documentation may include:
- Record of communications with physicians and health care providers. especially recommendations for proton therapy
- Evidence of previous treatments, health complications, and appointments with physicians
- Evidence of communication with the insurance company, including email correspondence and any notes you may have related to phone conversations.
This comprehensive evidence can overturn the insurer’s decision to deny coverage and increase the likelihood of a successful appeal.
4. Submit Your Appeal with a Formal Letter
When you embark on the appeals process (or, as your policy may call it, a “request for review”) for a proton therapy denial, the final crucial step is to compose a well-crafted appeal letter and submit it to your insurer. This letter should contain all the necessary information to substantiate the need for the proton beam therapy procedure and demonstrate its potential benefits in your case.
You can try to write an appeal letter yourself, but there is a lot at stake when your fight for coverage could be a life-or-death battle. That’s why you should work with our highly experienced proton therapy denial attorneys at Kantor & Kantor.
The following are important elements in this step:
- Address the appeal letter to the appropriate individual or department within the insurance company. Finding the correct recipient may take some research.
- You must send the appeal letter in hard copy rather than through email or other delivery methods. Traditional mail is the accepted and valid form of initiating the appeals process.
- Within the appeal letter, provide comprehensive details that support your case to win an appeal of your denial of proton beam therapy treatment.
- Clearly outline your physician’s reasoning for recommending proton therapy and emphasize why this procedure is ideal for treating your type of cancer.
- Highlight the unique benefits and advantages that proton therapy offers in your
- Include pertinent information about your medical history to bolster your appeal of the proton therapy claim denial. This may involve explaining previous cancer treatments that did not yield the desired outcomes or detailing specific medical conditions for which proton therapy has demonstrated remarkable effectiveness.
5. Consult Medical Research to Prove Why Proton Therapy Is the Ideal Treatment for You.
Our attorneys at Kantor & Kantor know the value of both medical research and individual medical records in an appeal for a denied claim. Extensive studies by medical researchers show that proton beam therapy (PBT) is the preferred treatment compared to traditional radiation: the efficacy is equivalent, and the side effects are fewer. The Mayo Clinic alone has done 37 studies on PBT.1 And, with less damage to surrounding tissue, the long-term side effects of PBT may be less than traditional radiation, too. What does this mean to your denied insurance claim? To support the appeal of your proton treatment denial, you can include medical documentation related to your individual treatment recommendations and to PBT in general. You may be able to show how costs related to side effects could be lower — offsetting the initial costs of PBT.
Furthermore, if you have fewer side effects, you suffer less during the treatment of your cancer. That’s a major reason why providers recommend PBT. It is an obvious choice when overall patient wellness is at stake.
Providing results of medical studies conducted by respected cancer centers or other researchers in relevant positions may be important to your appeal. It can help make your argument for why your claim for proton beam therapy should not be denied. Our attorneys at Kantor & Kantor will guide you in collecting data and can do so on your behalf. We provide here a glimpse at the available recent research on PBT.
The number of patients receiving proton beam therapy has increased over the past decade. Researchers found that almost 6 million breast and prostate cancer patients received PBT between 2004-2018.2 Medical providers specializing in the treatment of cancer at the University of Pennsylvania Roberts Proton Therapy Center have treated thousands of prostate cancer patients since 2010. They explain concisely why they chose this treatment rather than traditional radiation. Not only does its focused treatment leave healthy surrounding tissue unharmed, but Penn Medicine providers note that “[t]reatment sessions are quick, painless and result in minimal side effects for the vast majority of patients.”3
Oncology professors at the University of Pennsylvania in the Perelman School of Medicine and at the University of Washington St. Louis School of Medicine published a study in JAMA Oncology.4 They show that fewer side effects from PBT result in fewer unplanned hospitalizations. This reduction in the need for additional health care means fewer insurance claims, too. That lowers costs for insurance companies. Companies sometimes deny claims simply to protect their bottom line. When you show that future added costs related to radiation side effects may be avoided, you may get their attention.
At this point in the process, if you haven’t turned to a skilled legal professional, you should. A significant amount rides on winning your appeal of the insurance company’s denial of your proton therapy claim: your health, your future, and possibly your life.
6. Consider Hiring an Experienced Insurance Claim Denial Attorney
If you haven’t already done so, you should hire an attorney with the skills and experience needed to fight a proton beam therapy claim denial. Navigating the appeals process can be daunting, especially for individuals unfamiliar with the necessary steps. Any missteps along the way may jeopardize the chances of a successful appeal and result in further delays in receiving treatment.
Our California proton therapy lawyers have specialized knowledge about this area and will provide you with essential expertise as they build your proton beam therapy denial case. They can guide you through each step, increasing your chances of a favorable outcome and facilitating access to the necessary treatment essential for your health.
Is Your Proton Therapy Denial Governed by Federal Law?
ERISA is Highly Complex and Requires Specialized Legal Knowledge
If your proton beam therapy claim denial case isn’t complex enough, there’s yet another wrinkle: Which law governs your case, federal or state? The answer to that question lies in the answer to one simple question: Did you purchase your health insurance individually, or was it part of an employer-sponsored plan? If the latter is the case, then a federal law known as ERISA will apply.
Health insurance plans offered by employers are subject to regulation under the federal Employee Retirement Income Security Act (ERISA) of 1974. ERISA law governs employer-sponsored health plans, and its administration and enforcement fall under the responsibility of the U.S. Department of Labor. One of the key aspects of ERISA is the establishment of minimum standards for employer-sponsored health insurance, encompassing documentation, reporting, and fiduciary requirements.
With the help of our ERISA attorneys, you can confidently challenge a claim denial for proton therapy. We understand the nuances of ERISA cases and have exceptional knowledge of complex ERISA laws and legal cases.
FAQs about Proton Beam Therapy Insurance Denials Governed by California Law
Policyholders have rights protected by law regarding insurance bad-faith practices. In California, policyholders can seek legal remedies under the California Insurance Code and Fair Claims Settlement Practices Regulations. You may be allowed to file a bad-faith lawsuit against your insurance company and pursue compensatory damages for medical expenses, emotional distress, attorney’s fees, and, potentially, punitive damages for extreme misconduct.
You may be wondering, why is proton beam therapy not covered by insurance? If you suspect bad-faith insurance practices related to your proton beam therapy claim, it is important to take several steps. First, gather all relevant documentation, including your insurance policy, denial letters, medical records, and correspondence with the insurance company. Then consult a skilled attorney adept in handling insurance law cases to evaluate your case and determine the best course of action. They can guide you through filing a complaint, negotiating with the insurance company, or pursuing legal action, depending on the specifics of your situation.
Choose Your Best Option for Legal Representation
Contact Our Proton Beam Therapy Denial Lawyers Today
Proton beam therapy holds immense potential as a life-saving treatment, making it important for people to avoid wasting time in disputes with their insurance company regarding its effectiveness. Have you had a proton beam therapy claim denied? If you were unjustly denied the recommended treatment due to the insurer’s unwillingness to cover the costs, our proton beam therapy denial lawyers are here to assist you. We will thoroughly evaluate the specifics of your case and provide expert legal advice accordingly. Furthermore, we will gather the necessary evidence to substantiate your claim.
Whether your case is governed by state law or by ERISA, we have the knowledge you need to build a strong case to fight the denial of your proton beam therapy claim. With our dedicated support, we will guide you through the process of filing an administrative appeal and represent you during any hearings. We will protect your rights and diligently work to secure the treatment you need. If needed, we are prepared to file a proton beam therapy lawsuit on your behalf, ensuring your voice is heard throughout the legal proceedings.
Why wait? Get the legal help you need now. Call our proton beam therapy denial attorneys today at 818-886-2525 to schedule your 30-minute free consultation and find out how we can help.
Sources
1 Mayo Clinic. Clinical Trials. Proton Therapy. https://www.mayo.edu/research/clinical-trials/tests-procedures/proton-therapy Retrieved Sept. 27, 2023.
2 Leticia M. Nogueira, Ahmedin Jemal, and K. Robin Yabroff. Assessment of Proton Beam Therapy Use Among Patients With Newly Diagnosed Cancer in the US, 2004-2018. JAMA Network Open. 2022; 5(4):e229025. doi:10.1001/jamanetworkopen.2022.9025. April 27, 2022. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2791568
3 Penn Medicine. Abramson Cancer Center. The Benefits of Proton Therapy for Prostate Cancer. June 23, 2022. https://www.pennmedicine.org/cancer/about/focus-on-cancer/2022/june/proton-therapy-for-prostate-cancer
4 Julia Evangelou Straight. Proton Therapy as Effective as Standard Radiation with Less Side Effects. Washington University School of Medicine in St. Louis. Dec. 26, 2019. https://medicine.wustl.edu/news/proton-therapy-as-effective-as-standard-radiation-with-fewer-side-effects/
Attorney Glenn R. Kantor
Glenn Kantor is a founding partner of Kantor & Kantor LLP. As a young attorney, Glenn saw the injustice of wrongful insurance denials and created a law firm to represent individuals seeking to obtain their rightful benefits. Glenn is committed to ensure that clients receive the benefits they are entitled to under their insurance policies or group health plans. [Attorney Bio]
