Miami judge sides with cancer patient, orders insurer to cover pricey treatment

A Miami-Dade Circuit Court judge has ruled in favor of a cancer patient whose health insurer refused to cover a recurring $48,500 cancer treatment that could save his life.

Thursday’s ruling is a win for Doral resident Pablo Langesfeld, who has been in a back-and-forth with Oscar Health for months over the potentially lifesaving medication.

“We are very grateful for the outcome of this case. Our focus remains on my father’s health and ensuring he receives the care his doctors recommend,” Martin Langesfeld, Pablo’s son, told the Miami Herald in a text message shortly after the ruling. “No person should ever have to fight this hard to simply get the medical care they need.”

Circuit Court Judge Migna Sanchez-Llorens in her ruling described parts of Oscar Health’s policy, including its definition of “medically necessary,” as ambiguous, noting that Florida law requires ambiguous insurance contracts to be interpreted in favor of the customer, which in this case is Langesfeld. She ordered the health insurer to authorize and provide coverage for Langesfeld’s prescribed oral medication.

The verdict is a “big win for patients” who may find themselves in similar situations, Maria T. Santi of Health and Medicine Law Firm, one of Langesfeld’s attorneys, told the Herald.

Oscar Health did not immediately respond to a request for comment.

The dispute began in December, when Langesfeld’s in-network physician, Dr. Peter Hosein at Sylvester Comprehensive Cancer Center in Miami, prescribed him Avmapki Fakzynja Co Pack, an oral medication, “due to failed chemotherapy interventions” against his Stage 4 pancreatic cancer. The drug therapy is approved by the U.S. Food and Drug Administration to be used for ovarian cancer treatment and was granted an “orphan drug” designation in 2024 to encourage research and testing against pancreatic cancer, the third-leading cause of cancer-related death in the country.

The therapy has shown promise in trial results against metastatic pancreatic cancer. While Oscar approved coverage for Langesfeld’s chemotherapy, it refused to pay for the costly oral medication — which comes with a price tag of $48,500, every three weeks — arguing in court that the oral medication is “experimental,” not medically necessary and not federally approved to treat his cancer. Langesfeld’s attorneys sued, accusing Oscar Health of violating its own insurance policies.

Now, Langesfeld’s battle is over, and he’ll be able to add the drug therapy combo to his treatment regime.

“This has been a very stressful and challenging experience for me and my family,” Langesfeld told the Herald. “Managing my health while dealing with this process has been extremely difficult.”

Langesfeld’s family and his attorneys also see it as a win for frustrated patients who find themselves in a never-ending dispute with health insurers over off-label drug coverage.

“Doctors are being overshadowed by health insurances” who are “trying to dictate medical care for patients,” Santi said.

“The doctor knows what is right for his patients, not the health insurance,” she added, describing Thursday’s ruling as one that “will open the door” and likely lead to more patients getting their prescribed off-label drug covered.

The judge’s decision comes several weeks after the jury ruled in favor of Langesfeld, answering “yes” on four out of five questions related to whether the prescribed drug therapy is appropriate to treat his aggressive cancer.

“We are so gratified that the Judge and Jury carefully considered the important issues in this case and came to the correct and inevitable conclusion that Pablo is entitled to the drugs he needs,” attorney Todd Legon of Coral Gables-based Legon Fodiman and Sudduth, who represented Langesfeld alongside Santi, said in a statement. “Justice has been served not only for Pablo but for the countless others whose insurance companies deny coverage without justification every day.”

This is not the first time Oscar Health has been taken to court over policy violations. A federal judge in Texas ruled in favor of the New York-headquartered insurer earlier this year and dismissed a class action lawsuit that accused Oscar of violating state law and its own policies by requiring policyholders to pay deductibles and coinsurance for diagnostic breast imaging. An appeal has since been filed in the Texas case challenging the court’s decision.

©2026 Miami Herald. Visit miamiherald.com. Distributed by Tribune Content Agency, LLC.