There are a lot of steps between the time a treatment for a medical condition is first tested on human patients and the time it’s accepted as a medically proven treatment that insurers will generally cover under the policies they provide.
In between those points in time, testing and clinical trials take place. The people who participate in these phases may be seeking treatment for a serious or potentially fatal condition. They’re often willing to take the risk that they could suffer side effects not yet discovered if an experimental treatment is their best or only option because nothing else has worked or is likely to work.
The chances of your employer-sponsored health insurance covering this kind of treatment, however, are often slim. Health insurance policies typically have some language stating that the insurer has no obligation to pay for an experimental treatment, even if it’s been recommended by a physician treating a patient for a condition that may respond well to a particular approach.
Be prepared to provide plenty of evidence
Even if you don’t have any assurance that your insurance company will cover a specific, experimental treatment, you may choose to move forward with it and then submit a claim. If your insurer denies your claim on the grounds that the treatment is “experimental” or “investigational,” you have the option to appeal that denial. It’s important to be armed with information before you take this step in order to better ensure the success of your effort. For example, find out how the insurer defines “experimental,” since this definition can vary among insurance companies. Also clarify why your insurer categorizes your specific treatment as experimental.
It’s important to be able to provide your own evidence of the efficacy and safety of the treatment. A letter from your doctor detailing their success with the treatment, medical journal articles describing its effectiveness and any Food and Drug Administration (FDA) findings on the treatment can all be helpful.
Don’t assume that your insurer has all of the latest information on the treatment that it’s still classifying as “experimental.” Also note that even if your insurer has denied reimbursement for the treatment itself, it should still pay for any routine care related to that treatment – such as blood tests and follow-up exams by your regular physician.
If you’ve had reimbursement for a treatment denied on the grounds that it’s “experimental,” don’t assume that this is your insurer’s final decision. Consider seeking experienced legal guidance to help give you the best chance of a successful appeal.