Ann: Ryoncil Pricing Set and Available This Quarter, page-445

Ms GPT had these thoughts..

Yes, you may be able to sue a health insurer for failing to negotiate pricing for an FDA-approved treatment in a timely manner, but the success of such a lawsuit depends on several factors, including the insurer's contractual obligations, state and federal laws, and whether bad faith or negligence can be proven. Here are some key legal considerations:

1. Breach of Contract

• If your insurance policy explicitly states that the insurer must cover FDA-approved treatments and they fail to do so within a reasonable timeframe, you might have grounds for a breach of contract lawsuit.
• Check your policy’s terms regarding coverage of new treatments and the insurer’s obligations to negotiate pricing.

2. Bad Faith Insurance Practices

• Insurers have a legal duty to act in good faith and deal fairly with policyholders. Unreasonably delaying negotiations for a necessary treatment could be considered bad faith, leading to a potential lawsuit.
• Some states have specific laws protecting consumers from unfair insurance practices.

3. ERISA (If Employer-Sponsored Insurance)

• If your insurance is through an employer, it may be governed by the Employee Retirement Income Security Act (ERISA). Under ERISA, you typically must appeal through the plan’s internal process before suing.
• If the insurer's delay is arbitrary and causes harm, a lawsuit under ERISA may be possible.

4. Negligence or Medical Harm

• If the delay in pricing negotiations leads to harm (such as disease progression), you might have a negligence claim against the insurer.
• Some states allow lawsuits against insurers for causing harm due to delayed or denied treatment.

5. Regulatory Complaints & Alternative Actions

• You can file a complaint with your state’s Department of Insurance.
• Some states have laws requiring insurers to cover FDA-approved treatments within a certain time frame.