Hope for kidney cancer patient challenging insurer's decision

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by MIMI JUNG / KING 5 News

Bio | Email | Follow: @MimiJungKING5

KING5.com

Posted on March 26, 2012 at 2:21 PM

Updated Friday, Jan 4 at 10:45 AM

With every passing day, with every breath he takes, Art Gonzales is beating the odds.  He's a fighter in more ways than one.

For 14 years, he's been fighting Stage IV Renal Cell Carcinoma, a cancer that has ravaged his body.  But he's still alive.

"I can live on one kidney, can live on organ here, I can live on another organ here, just gotta keep fighting," said Gonzales. 

When he was diagnosed in 1997, Gonzales was given only months to live.  He immediately underwent surgery to remove one of his kidneys and a massive tumor on his spinal cord and he began treatment.  After two years, his cancer went into remission.  Just talking about that day brings tears to his wife's eyes.

For a decade, Gonzales went back to living a normal life, going to work and raising his two kids.  But in 2007, doctors discovered the tumors had returned.  This time, to his left lung, adrenal gland and pancreas. 

"I said, 'Well, where are the gloves? Give me the gloves, I'll start fighting it again,'" said Gonzales.

And when a brain tumor was discovered, Gonzales fought again.  He survived cyberknife surgery when doctors thought he was on his last leg.  As the cancer continued to spread, he exhausted all the standard therapies. 

So his oncologist at Seattle Treatment Cancer and Wellness Center prescribed Gemzar.  It's a drug usually given to treat pancreatic cancer.  Even though studies have shown Gemzar has been effective on a small group of kidney cancer patients, it's not FDA-approved to treat this type of cancer.  It's off-label and considered experimental, which means Gonzales's insurer, like many others, won't cover it.

"I never thought they would say no because Art has lived .. he beat the odds. And someone to beat it this far, why not give them an opportunity and a chance?" said Esther Gonzales, Art's wife.

Gonzales's employer, MultiCare, is self-insured and their insurance plan is administered by First Choice Health. The couple tried appealing with the help of Art's oncologist, who wrote letters and sent literature and research, hoping to convince the insurer to reverse its decision.  But their appeal was rejected.  Because of patient privacy issues, First Choice would not comment specifically on the Gonzales case. 

The Washington state insurance commissioner's office says what's happening to the Gonzales is a common story across the country.  The agency has a hotline to help consumers navigate through the maze of insurance coverage and helps them through the appeals process. 

People have no idea that there are multiple levels of appeals.  After appealing to the insurance company and getting rejected, there's still hope.

"After that you have a right to appeal to an independent review organization which is some other organization away from that insurance company with independent experts. And the insurance company pays the bill for that," said Mary Childers, Consumer Advocacy program manager.

Childers says almost 25 percent of consumers who appeal, win their appeals.

"Fight the fight, but don't quit because insurance companies up front deny claims based on standard processes and procedures. They're just looking at what is says on a piece of paper there," said Childers.

After receiving advice from the insurance commissioner's office, Art Gonazels is now pursuing an independent review, hoping to get First Choice to reverse its decision.  In the meantime, he has to pay thousands of dollars himself, for the one treatment that is keeping him alive.

Here's some advice from the State Insurance Commissioner's Office when it comes to appeals:

  • Always file an appeal with your insurer.  It may take more than once.  Don't give up.  Exhaust your appeal rights.  Read your policy.  A lot of insurers allow an independent medical review panel.
  • Call your state insurance commissioner.  We investigate insurance complaints on your behalf.  We can help get claims paid or policy decisions overturned.  (Every situation has its own set of circumstances.)
  • Even if there are no legal grounds for a consumer to file a complaint, we can offer advice.

The Insurance Commissioner's Office also has an Appeals Guide, which you can download online.

You can reach the Consumer Hotline at 1-800-562-6900.

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