Hilary Swank has filed a lawsuit against the trustees of the SAG-AFTRA Health Plan, asking a federal judge to order the trustees to resume coverage of her treatment for recurrent malignant ovarian cysts, which have afflicted the two-time Oscar-winning actress for more than 11 years.
Her lawsuit, filed on Tuesday in U.S. District Court in Los Angeles, says that beginning in 2009, she submitted claims to the plan’s precursor – the SAG Health Plan – for treatment of ovarian cysts, which the trustees initially denied but later agreed to cover. “However, in 2015, the Trustees reversed course and stopped allowing Swank’s claims for treatment of ovarian cysts. It also just so happened that around the same time as when the Trustees no longer agreed to allow Swank’s claims, Swank was undergoing procedures to preserve her ability to conceive in the future. Seizing upon Swank’s choice to keep her options open, the Trustees pointed to an exclusion in the Plan for ‘infertility treatment,’ relying on the notion that the only purpose of preserving the health of an ovary is to procreate.”
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“This matter addresses the shockingly antiquated question of whether the sole purpose of a woman, and specifically her ovaries, is to procreate,” says the lawsuit (read it here). “When faced with a claim for insurance benefits for the medically necessary treatment of ovarian cysts and endometriosis, the Trustees answered ‘yes,’ determining that there could be no possible reason to treat those conditions other than for the purpose of trying to conceive.”
The lawsuit begins with a quote from Margaret Atwood’s “The Handmaid’s Tale,” about women who are forced to reproduce: “As all historians know, the past is a great darkness, and filled with echoes.”
“Despite Swank’s, and her board-certified doctors’ insistence that she was not seeking coverage for fertility treatment, but only for treatment for her ovarian cysts, the Trustees dug in their heels,” the suit states. “The Trustees repeatedly said that there was no medically necessary reason to treat or monitor ovarian cysts other than for ‘infertility treatment.’”
This action is brought, the suit says, “for the purpose of obtaining benefits under the terms of an employee benefit plan; to clarify and enforce Swank’s past, present and future rights to benefits under an employee benefit plan; and to obtain other equitable relief, including an declaration that the Trustees must qualify Swank for the future receipt of benefits related to the treatment of ovarian cysts and endometriosis and to pay Swank benefits to which she is entitled; for pre-judgment and post-judgment interest; and for attorneys’ fees and costs.”
According to the suit, “A controversy now exists between Swank and the Trustees as to whether the Trustees are required to pay for treatment and monitoring of Swank’s ovarian cysts and endometriosis as determined to be medically necessary by Swank’s physicians. Swank contends that the Trustees are obligated to provide medical benefits for the treatment and monitoring of her ovarian cysts and endometriosis. The Trustees have denied these obligations and contend that they are not obligated to provide coverage for the monitoring and treatment of ovarian cysts and endometriosis. Therefore, declaratory relief is necessary to determine Swank’s rights under the Plan. Specifically, Swank seeks a declaration by this Court that the Trustees are required to pay for the requested treatment and in accord with her contentions above. A declaration is necessary at this time in order that the parties’ dispute may be resolved and that the parties be aware of their respective rights and duties.”
The suit then provides a timeline for her treatments and her battles with the health plan for coverage, beginning when she was initially diagnosed in 2008 and began submitting claims to the Plan for treatments the next year.
“In 2008, Swank was diagnosed with ovarian cysts. Ovarian cysts are known to grow rapidly and prolifically, and can result in debilitating pain, ovarian torsion, and significant hormonal imbalances,” it states. “Due to persistent ovarian cysts, Swank’s left ovary was destroyed and removed during emergency surgery in 2008. Since then, she has experienced recurrent cyst formation in her remaining ovary. Her history of ovarian cysts has shown that her ovarian cysts develop rapidly with a destructive nature, so she is required to frequently and carefully monitor the development of any cysts. Because of the cysts’ recurrence, she is frequently required to undergo aspirations of the cysts, sometimes multiple times per year.
“In 2019, Swank was also undergoing testing to further diagnose endometriosis. Endometriosis is known to cause the proliferation of uterine tissue outside of the uterus, often resulting in pain and digestive issues. Because of ovarian cysts and endometriosis, Swank suffers from extreme and debilitating degrees of acid reflux, pelvic pain throughout her lower abdomen, bloating, cramping, and fatigue, among other symptoms. Swank has and continues to receive treatment for ovarian cysts, including monitoring their growth and treating the cysts and endometrial tissue with ultrasounds, bloodwork, aspirations, and surgery as needed.
“Swank began submitting claims to the Trustees for coverage under the precursor to the Plan for her treatment related to ovarian cysts beginning in 2009. Initially, upon receipt, the Trustees denied coverage for these treatments, citing an exclusion for ‘infertility treatment.’ However, once Swank alerted the Plan’s precursor (the SAG Health Plan) to the fact that she was not trying to conceive in 2011, the Plan’s precursor agreed to cover all costs ‘for services in connection with the treatment of ovarian cysts.’
“Despite trying to treat Swank’s ovarian cysts with birth control pills, this form of treatment was ineffective. Instead, Swank’s doctors insisted on regular ultrasounds to monitor the growth of the ovarian cysts and surgical aspirations of the cysts as necessary. Swank continued to submit claims for the treatment of her ovarian cysts, and they were paid in part until late 2015. Between January 1, 2017, and continuing through the present, Swank continued to monitor and receive treatment for ovarian cysts and endometriosis through ultrasound monitoring of her remaining ovary and endometrial tissue growth. Swank also continued to exercise her constitutional right to privacy by undergoing treatments to preserve her ability to conceive at some point in the future if she so chose.
“Between January 1, 2017, and continuing through the present, Swank continued to submit claims for coverage for ultrasound treatments to monitor her ovarian cysts and endometriosis to the Trustees. Swank did not submit claims to the Trustees for any treatments undergone to preserve her ability to conceive and has made a conscientious effort to distinguish such treatments from treatments for her ovarian cysts. Swank’s treating physicians determined that ‘less intensive’ treatments for endometriosis and ovarian cysts, such as hormonal birth control pills, were not effective and therefore not a reasonable alternative, and recommended that the best course of treatment to save her sole remaining ovary was to monitor it with ultrasounds.
“The purpose of treating and monitoring Swank’s sole remaining ovary was unrelated to any ‘infertility treatment.’ Rather, Swank’s doctors were focused on saving her ovary to prevent the risk of debilitating medical conditions, including cancer, loss of estrogen production, premature menopause, osteoporosis, depression, hyperlipidemia (high cholesterol in the blood), coronary artery disease, arthritis, asthma, chronic obstructive pulmonary disease, chronic pain, fatigue, chest pain, heart palpitations, muscle spasms, insomnia, recurrent urinary tract and yeast infections, and even early death.
“However, in 2017, the Trustees informed Swank that none of the treatments post-dating January 1, 2016 would be covered under the Plan because they had decided that the treatment was ‘infertility related,’ and therefore not covered by the Plan.
“Following the Trustees’ decision, not only was Swank’s physical health suffering, but she was undergoing a great amount of emotional suffering as well. On top of Swank’s fear of not knowing when the next painful episode would occur, she had to contend with the mental weight of the Trustee’s oppressive position in refusing to protect the overall health of a woman. Instead, the Trustees put form over the substance of her treatments by repeatedly denying that there was any purpose for them other than for ‘infertility treatment.’
“In 2019, Swank filed a timely appeal of the denial of benefits. On October 8, 2019, the Trustees, acting on behalf of the Plan, sent Swank’s medical file to an anonymous OB-GYN doctor (the “Consultant”) for review. On October 14, 2019, the Consultant reviewed Swank’s medical records for the Plan. The Consultant upheld the Trustees’ denial of benefits, stating that ‘pelvic ultrasounds and laboratory testing provided for this patient was for the purpose of monitoring and treating infertility . . . not PCOS (ovarian cysts) or endometriosis.’
“On December 11, 2019, the Trustees requested clarification from the Consultant regarding the standard of care for both PCOS and endometriosis. On December 12, 2019, the Consultant re-reviewed Swank’s medical records and stated that ‘the testing and treatment provided for this patient were not standard of care for diagnosis or treatment of PCOS or endometriosis.’
“On December 18, 2019, the Trustees notified the Consultant that Swank’s treating physician requested a telephone conference with them. On January 2, 2020, a peer-to-peer review of Swank’s treatment was conducted by Swank’s treating physician and the Consultant via telephone. On the same date, the Consultant reported to the Trustees that based on the peer-to-peer discussion, the Consultant would uphold their previous decision for denial.
“On January 20, 2020, the Trustees notified Swank of their denial of her appeal and again suggested the use of ‘progestin, extended cycle combined oral contraceptives and NSAIDS’ as treatment options.
“On April 28, 2020, Swank took the last step available to her in the appeals process and requested an external review of the Trustees’ decision to deny coverage. Along with this appeal, Swank provided the Trustees with numerous letters from Swank’s treating physicians, all of whom stated that regular monitoring and treatment of Swank’s ovarian cysts was necessary to address Swank’s dangerous symptoms.”
The suit says that “Having exhausted her administrative appeals, Swank brings this lawsuit.”
The SAG-AFTRA Health Plan could not be immediately reached for comment.
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