Consumers Win in Michigan Insurance Transplant Case

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. Gleicher’s 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 Michigan’s Upper Peninsula.

‘Rider BMT’

"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 everybody’s 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 didn’t 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. Gleicher’s 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 transplant, said. "People like to bash lawyers, but I’m convinced my lawyers saved my life." Public health nurse Vicki Sluiter said, "She [Lisa Gleicher] just hung in there for so many people." Jan Banaszak, a breast cancer patient whom Ms. Gleicher represented in federal court, said, "It’s bad enough having cancer and then having to worry about the money. Blue Cross will take care of me now."

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. They’ll have to if they want to compete in this market. What I’d 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: help@bmtnews.org. The website address is http://www.bmtnews.org.