John Strauss And Michelle Strauss v. Premera Blue Cross
74600-6
| Wash. Ct. App. | Sep 5, 2017Background
- In 2008 John Strauss was diagnosed with intermediate-risk localized prostate cancer and consulted physicians about surgery, IMRT, and proton beam therapy (PBT); he preferred PBT and sought coverage.
- Strauss's Premera Blue Cross plan covered services that were "medically necessary," defined to require conformity with generally accepted medical standards and not be more costly than alternatives "at least as likely to produce equivalent" results.
- Premera's corporate medical policy (2009) and two independent medical reviewers concluded PBT was not medically necessary for clinically localized prostate cancer because it had not been shown superior to IMRT and was more costly. Premera denied preauthorization; an independent review organization and an external IRO upheld the denial.
- Strauss received PBT at his own expense (Feb–Apr 2010) and later sued Premera (2013) for breach of contract, bad faith, and violation of the Consumer Protection Act, seeking reimbursement and damages.
- Expert opinions conflicted: Strauss's expert (Dr. Laramore) opined PBT reduced side effects and was medically necessary; Premera's expert (Dr. Beer) and other reviewers concluded available data were insufficient to show PBT superiority over IMRT and that treatments were effectively equivalent.
- The trial court granted Premera’s summary judgment motion; the appellate court affirmed, holding Strauss failed to raise a genuine issue of material fact that PBT met the plan’s cost-effectiveness/medical-necessity standard.
Issues
| Issue | Strauss's Argument | Premera's Argument | Held |
|---|---|---|---|
| Whether PBT was "medically necessary" under plan language (not more costly than an alternative producing "equivalent" results) | PBT produced fewer side effects than IMRT (per Dr. Laramore and Dr. Bush); therefore it was not "more costly" relative to benefits | PBT is more costly and no clinical evidence from randomized head-to-head trials shows fewer side effects or superior outcomes; treatments are equivalent | Held for Premera: Strauss conceded PBT cost more and failed to show superior side-effect profile; no genuine factual dispute on medical necessity |
| Whether conflicting expert opinions created a genuine issue of material fact | Strauss argued expert testimony and studies create factual disputes on side effects | Premera argued experts relied on theory, indirect inferences, and nonrandomized/limited data insufficient to defeat summary judgment | Held for Premera: in absence of direct comparative clinical evidence, reasonable minds could only conclude treatments equivalent; expert inferences insufficient |
| Whether Premera acted unreasonably / in bad faith in denying coverage | Strauss argued denial was without reasonable justification given evidence supporting PBT benefits | Premera argued denial followed its policy, independent reviewers, medical literature, and guidelines | Held for Premera: denial based on reasonable grounds; summary judgment for insurer appropriate |
| Whether CPA claim survived summary judgment | Strauss contended insurer’s conduct violated consumer protection laws | Premera argued denial was reasonable and policy-compliant | Held for Premera: CPA claim dismissed along with other claims |
Key Cases Cited
- Baxter v. MBA Group Insurance Trust Health and Welfare Plan, 958 F. Supp. 2d 1223 (W.D. Wash. 2013) (summary judgment rejecting claim that proton therapy is superior to IMRT under similar policy language)
- Celotex Corp. v. Catrett, 477 U.S. 317 (U.S. 1986) (summary judgment burden-shifting framework)
- Hartley v. State, 103 Wn.2d 768 (Wash. 1985) (de novo review of summary judgment)
- Young v. Key Pharms., Inc., 112 Wn.2d 216 (Wash. 1989) (moving party’s burden to show absence of evidence)
- Smith v. Safeco Ins. Co., 150 Wn.2d 478 (Wash. 2003) (bad-faith denial standard; insurer entitled to summary judgment if denial based on reasonable grounds)
- Kut Suen Lui v. Essex Ins. Co., 185 Wn.2d 703 (Wash. 2016) (insurance contract interpretation principles)
- Quadrant Corp. v. Am. States Ins. Co., 154 Wn.2d 165 (Wash. 2004) (contract interpretation; insurance policies as contracts)