Medical science has grown by leaps and bounds over the past fifty years. Even now, doctors and researchers make groundbreaking advances every day that help people who were previously without hope. For many people, these advances offer new potential paths in providing treatment for their conditions.
Unfortunately, many health insurance companies do not see things in the same way. New clinical experimental trials or investigations into old problems are costly and not guaranteed to be successful. As such, insurers are often hesitant to provide payment for procedures that may or may not improve the health of their customers.
Still, any time an insurance company denies payment for an already received treatment or denies an insured treatment before it even begins, you have the right to appeal their decision. These appeals can be filed within the company itself or with the State of California. Either way, a Los Angeles experimental or investigational treatment denials lawyer may be able to help.
Why Might Experimental or Investigational Treatments Meet Resistance from Insurers?
The core concept behind medical insurance is a simple one. The insurer agrees to pay for any medical treatment that is necessary to save a person’s life or increase their quality of life. In exchange, the insured person agrees to pay premiums. Where hang-ups often occur is when the insurance company is making decisions as to whether the treatment is medically necessary.
Where this question receives the most consideration is when a person is seeking an experimental or investigational treatment for their condition. This typically occurs when a person has a disease or conditions that traditionally were considered untreatable or incurable.
However, it is not always the best option to seek new methods of treatment that are not fully established by medical science. While these experimental treatments are conducted by licensed doctors, their results are largely unknown.
Health insurance companies are not in the business of taking unnecessary risks with their money. If they do not believe that these treatments would have a beneficial effect on an insured’s health, they usually deny coverage.
The Legality of Experimental Treatment Denial
There is a substantial body of case law that deals with the concept of medical denials for experimental or investigational treatment. In general, courts have ruled that insurance companies are well within their rights to issue denials of coverage for experimental treatment. However, many insurance policies are written in such a vague or ambiguous manner as to be difficult to interpret. This vagueness has been the cause of many different lawsuits.
Even the concept of treatment being experimental can be difficult to define. In the case of Martin v. Blue Cross and Blue Shield of Virginia, the United States 4th Circuit Court of Appeals created a method for determining if a treatment is experimental, stating that when making such a decision in the future, courts should examine:
- The plain language of the policy
- The consent form given to the patient at time of treatment
- The protocol used by doctors
- The available medical literature
- The number of patients who have received this treatment in the past
A Los Angeles experimental or investigational treatment denials lawyer could work with potential clients on an individual basis to examine their medical needs, evaluate the case law that deals with their situation, and determine the best path forward to challenge the insurance company’s denial.
Talking to a Los Angeles Denials Based on Experimental or Investigational Treatment Attorney
Medical procedures and medications that are based on experimental or investigational treatments may be some people’s only hope for a recovery. However, due to their somewhat controversial nature, many insurance providers are hesitant to pay for these treatments. All people have a right to seek betterment in their lives after health insurance denials based on experimental or investigational treatment, and a Los Angeles lawyer may be able to help.
A Los Angeles experimental or investigational treatment denials lawyer could work to examine the reasons your claim was denied, investigate the relevant case law, file the appropriate appeals, and even go to court on your behalf to pursue the medical treatment you need. Contact our office today and we will help you.