Health insurance policyholders who are suffering from catastrophic or even life-threatening injuries, illness, and other medical conditions may find that their insurance carrier is not necessarily amenable to extending coverage to experimental treatments. Though the outcome of an experimental treatment may not be certain, and though there may be concerns about efficacy, safety, and long-term health, there are many patients who are left with no other recourse.
If your insurer has denied coverage for an experimental treatment that could fundamentally better your quality of life, or even save your life altogether, then you may be entitled to challenge their denial and obtain the benefits you deserve.
Let’s explore the basics of medical necessity and health insurance policies.
Medical Necessity, Cost-Effectiveness, and Other Concerns
Private health insurance plans vary quite a bit. Most insurance carriers offer health insurance coverage which requires that the policyholder demonstrate the “medical necessity” of their treatment in order to recover benefits. There may be various exclusions, conditions that automatically qualify for benefits, etc., but medical necessity is often the underlying concept through which all benefits determinations are filtered.
There is often no clear agreement about the meaning of medical necessity, however. Some insurers will argue that “medical necessity” must involve an evaluation of cost-effectiveness as well. Others will focus on the “need” aspect but may disagree that experimental treatment to improve a patient’s overall quality of life is medically necessary.
Experimental Treatments Involve “Sliding Scale” Considerations
As a general rule, experimental treatments are not clearly and uniformly beneficial. They may be disproportionately expensive in comparison to other treatments, have a low chance of success, and lead to substantial impairments. Certainly, if you attempt to paint the experimental treatment as “medically necessary,” your insurer will do everything they can to undermine that argument — they will demonstrate that the treatment is excessive, dangerous, and unlikely to resolve whatever injury, illness, or condition that you are seeking to treat.
In truth, arguments surrounding experimental treatments are a bit like putty. They can be transformed to suit whatever the opinion of the party making the argument. Whether they are worthwhile is a matter of framing the treatment in a positive way, and demonstrating that your injury, illness, and condition is sufficiently severe (and otherwise untreatable) that the experimental treatment is something of a last resort.
Contact an Experienced Miami Health Insurance Lawyer for Assistance
Ver Ploeg & Lumpkin, P.A. is an insurance litigation firm based out of Miami, FL, with a focus on providing client-oriented legal representation and achieving significant results — whether through internal administrative challenges, settlement negotiations, or at trial. Our relentless and thorough approach to handling insurance claims has served us well over the years. Since our founding, we have obtained substantial compensation for our health insurance policyholder clients.
The willingness of health insurers to deny claims often surprises policyholders who may be unfamiliar with the process of submitting an “edge-case” benefits claim. When possible, it is quite normal for insurers to deny claims (and otherwise act in an adverse manner to the policyholder) for which they can summon a half-hearted justification.
If you’d like to speak to a seasoned Miami health insurance lawyer about your dispute, call 305-577-3996 or send us a message through our Contact Us page to schedule a free and confidential consultation.Share