Coverage Denial, Out-Of-Pocket Payments Keep Proton Beam Suit Alive, Judge Says

Mealey's (January 29, 2021, 2:07 PM EST) -- OAKLAND, Calif. — An insurer never denies the claims at the heart of a reimbursement case — that the company originally denied coverage for a man’s proton therapy on the grounds that it was investigational, causing the man to pay out of pocket — a federal judge in California said in a Jan. 25 opinion denying dismissal.  In a footnote, the judge rejected the insurer’s claim that the insured could not demonstrate injury because the provider was paid, saying the plan specifically envisions payments to the insured for out-of-network care....