MADISON, Wis. (Legal Newsline)- The Wisconsin Supreme Court ruled Wednesday that a health maintenance organization erred when it refused to pay for special chemotherapy treatment for a cancer-stricken child.
In its 3-2 decision, the high court ordered Touchpoint Health Plan, Inc. to retroactively reinstate coverage for Parker Summers and his family.
Parker's father, Kevin Summers, received Touchpoint benefits through his employment with manufacturer Kimberly Clark Corporation.
Parker Summers was diagnosed with a malignant brain tumor in 2002. After the anaplastic ependymoma was removed, Dr. Diane Puccetti, a pediatric oncologist, prescribed high-dose chemotherapy with stem-cell rescue because it had a higher cure rate than conventional chemotherapy, court papers say.
Appleton, Wis.-based Touchpoint denied the treatment, saying Kimberly Clark Corporation's plan had an exclusion for experimental and investigational procedures; so, therefore the treatment would not be covered.
Writing for the majority, Justice N. Patrick Crooks said Touchpoint's decision was "arbitrary and capricious."
Crooks added that the court found that "the requested treatment met the standard of care and was medically necessary."
He said the termination letter of December 12, 2002, which Touchpoint sent to the Summers' family too was arbitrary and capricious, "because it did not provide a sufficient and adequate explanation of the reasons for Touchpoint's termination of benefits."
From Legal Newsline: Reach reporter Chris Rizo by e-mail at firstname.lastname@example.org.