Thousands of people throughout the United States are suffering needlessly, and many have died, because the lifesaving treatments their doctors ordered were denied by their health insurance companies. Without another way to pay for their necessary medical care, these people are forced to accept other treatments that may not be as effective. They often undergo alternative treatments that cause severe side effects. In some cases, patients lose their lives because they don’t have access to the treatments that can save them. Why are life-saving treatments denied by insurance companies? Profits before people.
What Is a Life-Saving Medical Treatment?
A life-saving medical treatment is a medication or medical procedure that is proven to extend or sustain a patient’s life. Without such treatment, the patient will likely die due to the illness. Examples of life-saving treatments include organ transplant surgeries, chemotherapy and other cancer treatments like proton beam therapy, artificial nutrition and dehydration, dialysis, etc.
Life-saving treatments are based on reasonable medical judgment and scientific evidence that demonstrates that the medication or procedure is effective in sustaining, prolonging, improving, or maintaining quality of life for the patient.
What Is a Medical Necessity?
A medical necessity is a type of judgment a doctor, clinical physician, or other healthcare professional makes regarding a medical treatment that is essential to the health, well-being, and survival of a patient afflicted with a serious medical problem. These determinations can be based on many factors, such as the severity of the medical problem, the symptoms and complications that the patient may experience, the amount of time the patient has to live depending on the severity of the complications, the essential nature of the treatment and its relation to the medical problem, and whether the treatment is within the regular standards in the medical field.
A medical treatment’s necessity to a patient’s health, well-being, and survival can be based on a doctor’s individual discretion. Your doctor may choose to provide you with treatment based on his or her opinion on what’s necessary, or he or she might refuse to give you treatment because the treatment may not be considered essential for your recovery. It may be important to get opinions from different healthcare providers to get a full understanding of your medical issues.
Medical necessities can include a variety of services, procedures, and operations. What is considered medically necessary for a patient’s health is based on sound judgment and expertise by the doctor treating you. Insurance companies can deny claims to pay for services, procedures, or operations if they consider these treatment methods to not be medically necessary to the patient.
Medical treatments are generally considered to be necessary for a patient’s health and safety if the lack of such treatments would negatively impact the health of the patient and put him or her at a risk of permanent injury, disability, or death.
Why Are Life-Saving Treatments Denied by Insurance Companies?
Life-saving treatments are denied by insurance companies for a variety of reasons. Sadly, most of the reasons are related to cost in one way or another. Insurance companies are for-profit companies. Their first priority is not the insured. It is their own bottom line. They take their own financial position so seriously, in fact, that they put their company’s profits ahead of the lives of our loved ones. They aren’t going to admit this, however, when you are begging them to pay for a medication or medical procedure that could save your spouse’s, your child’s, your parent’s, or your own life. Instead, they’re going to provide you with a “logical” sounding reason for why the life-saving treatment is denied.
Lack of Medical Necessity
Lack of medical necessity is one of the most common reasons insurers deny coverage. Even when a particular treatment has been deemed to be effective in treating a condition, has been scientifically proven to improve patients’ prognosis, and has been ordered by the doctor, the insurance company may say it is not medically necessary if there is a less expensive option available. This is often true even when the alternative treatment is not as effective or causes significant side effects.
A recent case involving proton beam therapy is a good example. The nation’s largest health insurance company denied proton beam therapy to a cancer patient, stating that other, less expensive treatments were just as effective. The other treatment they approved, however, came with multiple severe side effects that would not have occurred if the patient had access to PBT. As a result, the patient spent his last weeks suffering, his condition got worse, and he passed away. While the insurance company was sued, and the lawsuit brought a massive verdict in favor of the plaintiff, the damage was already done.
Another example involves procedures that insurance companies claim are “cosmetic” and therefore not medically necessary. Some treatments, like liposuction, are automatically processed by insurance companies as “cosmetic”, but they are medically necessary for treating disabling conditions, like lipedema. Without the treatment, patients are left in chronic pain and disabled.
The Treatment Is Not Covered
The insurance policy’s terms will say what treatments are covered by the insurance company. If the medical treatment you seek is excluded by the insurance policy, the insurance company will refuse to pay for your life-saving treatment. It is best to review your insurance policy before making important medical decisions.
The Treatment Is Investigational
Insurance companies typically only provide coverage for medical treatments that are proven and regularly performed by doctors and hospitals. If your medical treatment has not been proven effective, isn’t established in the medical field, is not regularly practiced in the medical industry, or seems to be included in a scientific research effort, most insurance companies will deny coverage for those treatments.
Errors in the Claim Filing Process
Any kind of technical error, such as not correctly spelling the name of your healthcare provider or submitting your information late, can be reasons for insurance companies to delay or deny your claim.
Unfair/Bad Faith Claim Denial
Some insurance companies will use arbitrary or unreasonable excuses to not review your claim or deny coverage. These reasons can vary, but contacting a bad faith insurance lawyer may help you understand if your insurance company has committed bad faith in denying you coverage.
If your doctor prescribed you a life-saving treatment, it is unreasonable for the insurance company to disagree that it is, in fact, medically necessary. You have a right to fight back, and you have the right to have access to the medical care you need. An attorney can help you review your coverage plan and the terms of the company’s insurance policy, find proof that your treatment is life-saving and is based on a medical necessity, appeal the denial to your insurance company, and file a lawsuit against your insurance company to recover compensation if you paid for your treatment expenses out-of-pocket.
Which Life-Saving Treatments Are Frequently Denied?
The type of life-saving treatments that are frequently denied are proton beam therapy, treatments that are designated by the insurance company to be investigational or experiential, cosmetic or elective procedures, and treatments that come from newer technology or services.
Proton beam therapy is a medical procedure that uses protons to destroy tumors and cancer cells. Proton beam therapy can be more effective than other methods of cancer treatment, but it can be more expensive. Proton therapy denials happen because insurance companies want to save money and not provide coverage for treatments they see as excessive in cost, especially if many people are choosing to get this type of treatment.
Medical treatments that are investigative or experiential in nature will usually be denied coverage by insurance companies. Insurance companies want medical treatments that have been proven to work and are normally conducted in the medical industry. Treatments that are cosmetic or elective are denied coverage because they are not seen as medically necessary. Medical treatments that come from new technology or services that are unfamiliar to most people in the medical industry can be seen as experimental in the eyes of health insurers. Life-saving treatments can be denied depending on many factors, but insurance companies have exceedingly denied these treatments.
What Should You Do If Your Treatment Claim Is Denied?
If your life-saving treatment was denied by your insurance company, there are steps you could take to recover compensation if you paid out-of-pocket expenses because you did not receive coverage. The first step if you have had your life-saving treatments denied is to review your insurance policy’s terms and see if your treatment is excluded or not listed. Obtaining evidence of your medical necessity can help make your claim stronger. A doctor’s note, an official diagnosis, test results, x-ray exams, and other medical documentation helps prove your claim.
You can also choose to appeal your denied claim back to the insurance company. Filing a lawsuit against your insurance company for denying your claim to provide coverage for your life-saving treatment is another beneficial option. If all other options have been exhausted, you can try your luck to recover compensation with the help of an attorney. A lawsuit against your insurance company may be your last-resort option to recover out-of-pocket expenses due to your claim being denied.
Chicago personal injury and workers’ compensation attorney Howard Ankin has a passion for justice and a relentless commitment to defending injured victims throughout the Chicagoland area. With decades of experience achieving justice on behalf of the people of Chicago, Howard has earned a reputation as a proven leader in and out of the courtroom. Respected by peers and clients alike, Howard’s multifaceted approach to the law and empathetic nature have secured him a spot as an influential figure in the Illinois legal system.