In August 2018, prominent trial lawyer Robert “Skeeter” Salim faced a denial from Blue Cross and Blue Shield for the proton therapy prescribed by his oncologist to combat stage 4 throat cancer. Despite being a celebrated litigator, Salim encountered resistance from the insurer, leading to a determined legal battle.
Following a diagnosis of massive oral disease, Salim’s oncologist recommended proton therapy, a precise radiation treatment. Despite marking the request as urgent, Blue Cross and Blue Shield rejected the claim, asserting that proton therapy was only appropriate after attempting other methods for irradiating the head and neck.
Undeterred, Salim, known for his successful pursuit of settlements from major corporations, opted to pay $95,862.95 out of pocket for proton therapy at the MD Anderson Cancer Center. This marked the beginning of a Goliath vs. Goliath legal showdown.
Angry at the denial, Salim initiated an appeal, a rare move for patients facing claim denials. The insurance industry’s reliance on external companies for claim reviews became apparent, with little consultation of outside medical sources. Despite Salim’s oncologist providing extensive evidence supporting proton therapy, the denial persisted through multiple reviews.
Enter Salim’s childhood friend and lawyer, Ronald Corkern, who took on the challenge. Facing the complexities of the Employee Retirement Income Security Act (ERISA), a federal law governing Salim’s insurance, Corkern sued Blue Cross. The insurer argued its authority to determine medical necessity, but Salim’s doctor, Dr. Clifton Fuller, highlighted flaws in the guidelines used for denial.
In a surprising turn, a federal magistrate ruled in Salim’s favor, criticizing Blue Cross for abusing its discretion. This decision, supported by Fuller’s evidence, marked a significant development in the case. Blue Cross appealed, emphasizing an “important issue” regarding ERISA benefits interpretation. Ultimately, the Fifth Circuit Court of Appeals sided with Salim in May 2023.
While Salim is now cancer-free, the case’s financial resolution remains open. Blue Cross is contesting the full payment Salim seeks, proposing a discounted rate negotiated at the time of treatment approval. Legal experts believe the case may influence future considerations of proton therapy’s medical necessity. Salim, viewing the lawsuit as successful, emphasizes the importance of recognizing the effectiveness of proton therapy.
Original Source: https://www.propublica.org/article/blue-cross-proton-therapy-cancer-lawyer-denial
