Jacobs v. Guardian Life Insurance Co.

William Jacobs (plaintiff) was diagnosed with a rare form of bile duct cancer. Jacobs’s physician prescribed a chemotherapy regimen involving off-label combinations of some drugs. Jacobs’s insurer, Guardian Life Insurance Co. (defendant), denied coverage under the language of the policy excluding drugs and treatments that were experimental and not medically necessary. Guardian maintained that if a combination of drugs is not the subject of a clinical trial or a specific Food and Drug Administration (FDA) approval for the specific condition, then it is within Guardian’s purview to deny covering that drug combination—notwithstanding the treating physician’s belief that the drug combination has improved the insured’s condition and kept the insured alive. Jacobs appealed Guardian’s denial of coverage, and in eight peer-review reports from three peer-review agencies, independent peer-review physicians concluded that the combination drug therapy was not medically necessary, was experimental, and was not supported by sufficient clinical studies nor accepted as appropriate by a professional medical society to treat this type of cancer. Jacobs offered no evidence to dispute Guardian’s contention that the treatment was experimental under the policy exclusion. Jacobs sought judicial review and alleged that Guardian’s denial of coverage was arbitrary and capricious.