Big Insurance Met Its Match When It Turned Down a Top Trial Lawyer's Request for Cancer Treatment : nottheonion

The article basically says that the lawyer was going to get some cool new expensive treatment for his cancer but his insurance company rejected it as being unnecessary. The 'on the books' reason they do this is because health care providers will sometimes advise on expensive treatments to milk insurance, like how a home repair contractor might draw up a very large quote for something like hail damage or flood repairs. Insurance companies have (probably) outsourced wagies make the determination. It was denied and the lawyer appealed, then it went to literal doctors who work for the company handling the appeal. They cite research and opinion to explain why a treatment isn't needed.

After many appeals, the lawyer went ahead with the treatment and found a friend to help sue Blue Cross. The decision was that Blue Cross' evidence was "outdated or did not pertain to the treatment". Also the lawyer representing the cancer-haver actually co-authored 17 studies about the this specific type of treatment, so that helped the case. Lawyers win, insurance loses.

Interestingly, he paid about $96k for the treatment but insurance only needs to pay him $35k because that's what they would have paid if they had covered the treatment to begin with.