Claim Denials Based on “Experimental” Treatments

When insurance companies get it wrong, Gianelli & Morris makes it right

Health insurance providers rely heavily on three reasons for denying their insured customers’ claims for health care benefits: that the sought-after treatment is experimental, that it is investigational, or that it is not medically necessary. Often, these reasons for claim denial are advanced by health insurers as a way to save money by forcing the policyholder to abandon their claim, rather than because the treatment is truly considered experimental or unnecessary. Patients who challenge these claim denials may be able to receive the treatment they deserve under the terms of their health insurance plan and may even be entitled to compensation for the bad faith conduct of the insurer in denying these claims.

In the first of a series of blog posts on these common reasons for wrongful claim denials, read on for an explanation of what it means for an insurer to deny benefits based on the experimental nature of a treatment. Contact an experienced California bad faith insurance attorney for more information on health insurance bad faith.

Treatment denied as “experimental,” explained

In order to keep costs down, health insurance providers deny claims for benefits if the treatment being sought is deemed “experimental” by claims adjusters. Insurers will consider a treatment or procedure “experimental” if the treatment hasn’t yet received FDA approval, and/or if it hasn’t yet received wide recognition by the community of medical professionals as a safe and effective treatment for your condition. Often, insurers will attempt to claim that a procedure is experimental even when the treatment has been approved for widespread use for years. For example, despite the fact that Artificial Disc Replacement surgery has had approval from the FDA for over 15 years, insurers still deny the procedure as experimental.

How patients can challenge the denial of a treatment as “experimental”

• Find out if the denial was accidental: One 2017 study found that between 30% and 90% of all medical bills from insurers contained errors of one kind or another. In some cases, medical providers had used the wrong billing code when submitting a claim for coverage. In other cases, the insurer had committed the error. Patients who have had a claim denied should first ensure that they have not been the victim of one of these errors that, if corrected, could lead to a speedy resolution of their problem.

• Get your doctor’s support: If the so-called “experimental” treatment was recommended to you by your physician, there’s probably an excellent reason why they made the recommendation that they did. Your physician may be able to provide documentation or other evidentiary support explaining that the treatment is regarded as safe and accepted for patients with your condition.

• Figure out if the procedure has received approval from physicians and government agencies: Sometimes, research will reveal that a given procedure is far from experimental and has in fact had widespread support from the medical community for years. If the FDA has approved of the treatment, if Medicare approves the treatment for its insureds, or if the treatment has received general acceptance by physicians in the field, then your insurer may be compelled to approve the treatment for you. A lawyer who is experienced in wrongful claim denials can help you gather this type of evidentiary support when appealing a health insurance claim denial.

Get the Right Kind of Legal Help with an Insurance Claim Denial

If you or a loved one has been the victim of a wrongful claim denial in California, get help challenging the denial and seeking potential bad faith damages by contacting the dedicated and effective Los Angeles bad faith insurance lawyers at Gianelli & Morris for a free consultation at 213-489-1600.