Insurance companies are unable to properly provide coverage to one Ottawa woman since her medication is an experimental drug used to treat cancer, not her specific health condition.
Forty-four-year-old Theresa Bertuzzi was diagnosed with autoimmune disease, which meant her immune system would indiscriminately attack parts of her body. It initially manifested in the form of hair loss, but over time Bertuzzi developed Raynaud’s Syndrome (where her fingers would turn black when she went out in the cold), Sjogren’s Disease (which led to her losing teeth), and Lupus.
Thanks to a combination of drugs, steroids and chemotherapy, Bertuzzi’s Lupus was put in remission. She, however, started having bouts of paralysis – the symptoms of a potentially fatal disease called Dermatomyositis.
“My family would have to dress me and carry me up the stairs. It was frightening,” Bertuzzi told CTV. “One day you can walk to the store, the next day you couldn’t get to the store, the next day you couldn’t lift the milk bag.
“Any day my autoimmune disease could start attacking my heart and my lungs and at that point it could mean the end of my life.”
Her doctor told her that the only treatment that could have a chance of mitigating her symptoms is a costly drug called Rituxan. Approved by Health Canada for cancer treatment, Rituxan is still at the clinical trial stage for patients experiencing Dermatomyositis.
For Bertuzzi’s condition, she would need a single dose of Rituxan every six months, worth $10,000.
When she put her claim through to her insurers, Sun Life Financial and Desjardins, both companies denied her claim. Her doctor sent letters, appealing the decisions, but the insurers rejected the claims.
When reached for an opinion on the matter, Desjardins reasoned that it denied Bertuzzi’s claim because the drug was unapproved for Dermatomyositis treatment.
“We understand how difficult the situation is but in this particular case, Health Canada has not approved this particular drug for the specified condition,” a Desjardins spokesperson told CTV in a statement. “When that is the case, it is standard practice that we consult the appropriate professionals and multiple medical references to ensure there is evidence for successful use of that drug before we approve the claim. In this case, our review indicated that the evidence of this drug for this condition is insufficient.”
A spokesperson for Sun Life said that the company empathizes with Bertuzzi and would attempt to reach out to her family to discuss once again the circumstances of their claim.
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