Schneiderman sues CDPHP for denying coverage of hepatitis C

ALBANY, N.Y. — Capital District Physicians’ Health Plan (CDPHP) is facing a lawsuit that accuses the Albany–based health plan of “unlawfully restricted coverage” of hepatitis C.

The office of New York Attorney General Eric Schneiderman announced the lawsuit in a news release issued Thursday.

Schneiderman’s office describes Hepatitis C as “a potentially life threatening condition,” but also notes that several medications are currently available that can “completely cure” hepatitis C.

The lawsuit alleges that CDPHP denied coverage for such treatment unless the member demonstrated advanced disease, such as moderate to severe liver scarring.

Members diagnosed with early-stage, chronic hepatitis C infection must monitor their disease and wait until they develop liver scarring or “other advanced disease” before CDPHP will cover their treatment, Schneiderman’s office said.

“When consumers purchase health insurance, they rightfully expect that if they are diagnosed with a serious, potentially life threatening disease like hepatitis C, treatment will be considered ‘medically necessary’ and covered by their insurance,” Schneiderman said in the news release. “Forcing patients to wait for care, risking internal organ damage, is unconscionable and, as we allege in our lawsuit, violates the law and the company’s own policies.”

Hepatitis C is a blood-borne virus that can cause chronic infection of the liver and an estimated 25,000 new cases of infection occur each year across New York, according to Schneiderman’s office.

Chronic hepatitis C infection can cause liver failure, liver cancer, brain damage, and kidney failure. If left untreated, it can result in cirrhosis “and be fatal.”

Hepatitis C is contracted through blood, including through intravenous needles, contaminated blood products (before blood was routinely screened starting in 1992), and, less commonly, through sexual intercourse, the office added.

Health plan reaction
CDPHP currently covers hepatitis C prescription-drug treatments “in a manner comparable to virtually every other health plan,” and in some cases, its coverage “goes further,” Ali Skinner, director of strategic communications at CDPHP, said in a company statement.

“Our policies are developed by an independent medical-policy committee which, in collaboration with our community physicians, determines the scope of coverage, utilizing scientific and evidence-based analysis. The guidelines for coverage are comparable with the state’s own guidelines for Medicaid. Despite an ongoing dialogue between the entire industry and the state, the attorney general’s office has chosen CDPHP, a national leader in quality and customer satisfaction, to initiate litigation on this matter. Our coverage decisions are made based upon the use of evidence-based clinical criteria, not upon political agendas or actions,” said Skinner.

CDPHP, a nonprofit health insurer based Albany, and its affiliates serve more than 385,000 people in 24 counties throughout New York, including Broome, Chenango, Herkimer, Madison, Oneida, and Tioga counties, according to the CDPHP website.

Contact Reinhardt at ereinhardt@cnybj.com