Blue Shield of California has attributed a “routing” mistake in its phone system for the failure of a San Francisco firefighter’s oncologist to contest a denial of a claim for his cancer treatment.
Dr. Matthew Gubens, who attended to veteran firefighter Ken Jones, attempted to appeal the denial right after receiving the notice—he called the number provided on the letter. Unfortunately, the number was directed toward a patient service line, which meant doctors couldn’t successfully file the appeal as planned.
Jones, who dedicated 17 years as a firefighter in San Francisco, faced a difficult insurance claims dispute in the closing months of his life. He passed away last month at 71 due to stage IV lung cancer.
The insurer clarified that the contact number on the denial letter was meant for members, and noted that Jones’ doctors were shuffled between different providers.
This insurance provider has had its share of challenges this year after denying parts of Jones’ needed cancer care. While chemotherapy was approved and covered, it proved to be only partially effective.
Dr. Gubens also recommended immunotherapy to help Jones’ immune system combat the cancer; however, Blue Shield never greenlit that treatment.
Blue Shield denied Jones’ claims twice. After the first rejection, Dr. Gubens found himself unable to successfully appeal via phone but decided to submit a written appeal instead. Unfortunately, that too was declined.
Dr. Gubens remarked previously, “All of our cancer treatments are harder to deliver and less effective the weaker the patient we are seeing.” He emphasized that even for someone facing terminal illness, the quality time extended can hold immense value for both the patient and their families.
Blue Shield insisted for months that Jones’ claim could not receive approval because medical protocols do not permit the combination of chemotherapy with immunotherapy.
Janine Nicholson, a former chief of the San Francisco Fire Department and a long-time friend of Jones, expressed her belief that the insurance company’s actions may have quickened his death. “They should be ashamed,” she stated.
At that time, Nicholson highlighted the need for insurance companies to be held accountable, suggesting that they often prioritize business interests over the wellbeing of people.
Blue Shield competes with Kaiser Permanente and Health Net in San Francisco, where the city spends over $1 billion annually to provide health insurance for roughly 40,000 employees and retirees.
