Recent Court Decisions

By Stempel, Jeff | Journal of Risk and Insurance, June 2001 | Go to article overview

Recent Court Decisions


Stempel, Jeff, Journal of Risk and Insurance


HEALTH PLANS EXCLUSION FOR ORGAN TRANSPLANTS DOES NOT EXCLUDE COVERAGE FOR HIGH DOSE CHEMOTHERAPY WITH PERIPHERAL STEM CELL RESCUE To ATTACK BREAST CANCER

Simkins v. NevadaCare, Inc., 229 EM 729 (9th Cir. 2000) (applying federal common law)

Ruby Simkins worked for M & K Enterprises, her husband's company. In October 1996, she was diagnosed with Stage I breast cancer, which her doctors treated with radiation. The treatment was initially successful, but she was advised that she would not be considered "cured" unless she remained free of cancer for five years. In late 1997, M & K switched healthcare providers and signed on with NevadaCare, with Simkins enrolling as a participant effective January 1, 1998. In 1998, Simkins was diagnosed with Stage IV breast cancer, as doctors discovered "at least 12 nodules in her lungs and a plum-sized mass on her liver." She went to UCLA Medical Center for treatment. 229 F.3d at 731.

Simkins's doctor recommended that she undergo high dose chemotherapy with peripheral stem cell rescue (HDC/PSCR). Stem cells are immature cells in bone marrow that mature to produce blood cells that then circulate throughout the body. Under the HDC/PSCR procedure, a patient is given an injection of drugs to stimulate stem cell reproduction and mobilization out of bone marrow and into circulating blood.

Then, through a series of transfusions, blood is removed from the patient's body and, after passing through a machine that filters out the stem cells, it is returned to the body. This "harvesting" procedure may be performed multiple times to collect enough stem cells. During the next phase of the procedure, the patient is given extremely high doses of chemotherapy (HDQ to try to kill off all of the cancer cells, a process that also kills off many of the patient's healthy cells. To help the patient recover more rapidly from the HDC, she is given a transfusion of the previously collected stem cells, which will migrate through the bloodstream into the bone marrow with the hope that they will take hold, grow, and produce mature red and white blood cells and platelets. 229 F.3d at 732.

Simkins sought coverage of the HDC/PSCR treatment from NevadaCare, which denied coverage, invoking the exclusion in the group health plan for "organ transplants." In the wake of the denial, she secured other funds, underwent the procedure, and was doing well as of the time of the court's opinion. Her suit was one for reimbursement of treatment costs under the NevadaCare plan. The trial court granted summary judgment for NevadaCare, but the court of appeals reversed, finding coverage for Simkins.

The health policy in question specifically provided coverage for blood transfusions and chemotherapy but excluded coverage for most organ transplants (except for limited exceptions set forth in the policy). The policy stated that "[t]issue transplant coverage is limited to allogenic bone marrow only." Simkins argued that she was not seeking an organ transplant but rather a transfusion of her own stem cells, which was akin to only a blood transfusion or bone marrow infusion. See 229 RM at 735. The Court of Appeals concluded as follows:

We hold that the district court erred in not considering whether a person of average intelligence and experience would construe the term "tissue transplant" to encompass HDC/PSCR. We believe the average person would not understand the term "tissue transplant" to encompass HDC/ PSCR, because she would not understand stem cells to be "tissue." Instead, the average person would focus on the fact that stem cells in this procedure are a component of the patient's blood. Indeed, the research study consent form Simkins signed specifically mentions that the stem cells would be collected from her blood stream. The average person is not likely to understand blood to be tissue .... Because stem cells would not be understood to be tissue, the average person would have no reason to believe the tissue transplant exclusion extended to HDC/PSCR.

The rest of this article is only available to active members of Questia

Sign up now for a free, 1-day trial and receive full access to:

  • Questia's entire collection
  • Automatic bibliography creation
  • More helpful research tools like notes, citations, and highlights
  • Ad-free environment

Already a member? Log in now.

Notes for this article

Add a new note
If you are trying to select text to create highlights or citations, remember that you must now click or tap on the first word, and then click or tap on the last word.
One moment ...
Project items

Items saved from this article

This article has been saved
Highlights (0)
Some of your highlights are legacy items.

Highlights saved before July 30, 2012 will not be displayed on their respective source pages.

You can easily re-create the highlights by opening the book page or article, selecting the text, and clicking “Highlight.”

Citations (0)
Some of your citations are legacy items.

Any citation created before July 30, 2012 will labeled as a “Cited page.” New citations will be saved as cited passages, pages or articles.

We also added the ability to view new citations from your projects or the book or article where you created them.

Notes (0)
Bookmarks (0)

You have no saved items from this article

Project items include:
  • Saved book/article
  • Highlights
  • Quotes/citations
  • Notes
  • Bookmarks
Notes
Cite this article

Cited article

Style
Citations are available only to our active members.
Sign up now to cite pages or passages in MLA, APA and Chicago citation styles.

(Einhorn, 1992, p. 25)

(Einhorn 25)

1

1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25, http://www.questia.com/read/27419298.

Cited article

Recent Court Decisions
Settings

Settings

Typeface
Text size Smaller Larger
Search within

Search within this article

Look up

Look up a word

  • Dictionary
  • Thesaurus
Please submit a word or phrase above.
Print this page

Print this page

Why can't I print more than one page at a time?

Full screen

matching results for page

Cited passage

Style
Citations are available only to our active members.
Sign up now to cite pages or passages in MLA, APA and Chicago citation styles.

"Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn, 1992, p. 25).

"Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn 25)

"Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences."1

1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25, http://www.questia.com/read/27419298.

Cited passage

Welcome to the new Questia Reader

The Questia Reader has been updated to provide you with an even better online reading experience.  It is now 100% Responsive, which means you can read our books and articles on any sized device you wish.  All of your favorite tools like notes, highlights, and citations are still here, but the way you select text has been updated to be easier to use, especially on touchscreen devices.  Here's how:

1. Click or tap the first word you want to select.
2. Click or tap the last word you want to select.

OK, got it!

Thanks for trying Questia!

Please continue trying out our research tools, but please note, full functionality is available only to our active members.

Your work will be lost once you leave this Web page.

For full access in an ad-free environment, sign up now for a FREE, 1-day trial.

Already a member? Log in now.