Merritt Personal Lines Manual: Lifestyle Medicine
In July 1998, 77-year-old Mouis Marcil filed a lawsuit against Kaiser Permanente for refusing to cover Viagra, the impotence drug introduced a few months earlier by Pfizer Corp.
The lawsuit was filed in Los Angeles Superior Court on behalf of Marcil, a retired sales manager living in Burbank, Calif., who was a client of Kaiser's Senior Advantage managed care program. Marcil claimed to have become impotent in 1996 due to radiation treatment for prostate cancer; he said he had received a prescription for Viagra in April from his Kaiser urologist but was told the HMO would not cover the $10-per-pill cost.
Kaiser Permanente, based in Oakland, California, excluded Viagra from its regular benefits contracts. The HMO, however, said it would pay for the drug if supplemental benefits coverage were purchased.
Kaiser's main concern was that covering the drug would raise policyholder premiums. It estimated that full coverage of Viagra would cost at least $100 million annually.
The suit charged Kaiser with fraudulent and unfair business practices and said that Kaiser's contract provided for coverage for prescription drugs without excluding any particular class of drug except those used solely for cosmetic purposes.
According to Marcil's lawyer, Frank N. Darras, Kaiser's marketing materials for Senior Advantage claimed it would cover customers' prescription needs for at least 100 days. "Kaiser promised to cover all their health care needs," said Darras. "When it came time to pay for Viagra, they would not honor the words of their contract."
Kaiser had been paying for Viagra coverage for a small number of patients for whom a doctor had deemed it a medical necessity, said spokesman Jim Anderson.
Marcil, who had been married 52 years, said he had been purchasing the drug himself and found it effective. He was suing for the $50 he had spent on the five Viagra pills he'd purchased so far and for emotional distress. No dollar figure had been set for the emotional distress element of the suit, as per California law.
In another case involving prescription drugs, NYLCare Health Plans of the Mid-Atlantic Inc. was accused of non-compliance with a Maryland law that entitled certain patients to a 90-day supply of prescription medication.
In 1997, the Maryland Insurance Administration brought a sanction against the company after it received complaints between April and September that NYLCare had denied members covered by its prescription drug rider the 90-day supply, according to an order signed by Maryland Insurance Commissioner Steven Larsen.
Under the Maryland law, health plan members who required so-called "maintenance medication" for chronic conditions were entitled to a 90-day supply each time a prescription was refilled. The 90-day supply could not be limited to purchase through a mail-order program.
NYLCare contended that it had complied with the law by making 90-day supplies available exclusively through its mail-order service. The HMO said administrative problems prevented it from providing wider access to members whose plans were effective prior to July 1998. It didn't prevail.
