The answer to the question of “Can insurance companies deny cancer treatment?” is often different from the answer to the question of “Do insurance companies deny cancer treatment?”
Although federal law often prohibits insurance companies from denying certain vital cancer treatments, patients are often forced to fight for coverage. In some cases, patients may even end up paying for the necessary treatment out of their own pockets because they cannot afford to lose time waiting to receive an insurer’s authorization before beginning treatment. Some patients may be forced to take legal action against their insurance company to get the vital coverage they need. One of the most common reasons why cancer patients must fight insurance companies is that they have been denied coverage for proton beam therapy treatment.
Federal Law Places Requirements on Health Insurance Companies
The Affordable Care Act made numerous changes in the law that governs how and when insurance companies must cover illnesses like cancer. Health insurance providers are no longer able to deny coverage on account of pre-existing conditions, nor can they impose yearly or lifetime caps on the amount of coverage that they provide. Insurance plans must cover essential health benefits that include cancer treatments.
In practice, insurance companies push the limits as far as they can to save themselves money. It is, unfortunately, all too common for patients to either have to fight to get the coverage they need or have it denied altogether.
Health Insurance Companies Have Often Flouted the Law
A relatively recent survey by the Texas Medical Association revealed that roughly one in every four people have had coverage for treatment prescribed by their doctor denied by an insurance company, notwithstanding the requirements of the Affordable Care Act. This includes people who have critically needed life-saving cancer treatment. Some patients’ conditions grew worse after having been denied the treatment or taking the time to fight the denial of coverage.
Insurance companies give many reasons for their denial of coverage of certain medical treatments to save themselves money at the expense of cancer patients, including:
- The cancer treatment is medically unnecessary
- The treatment is experimental in nature
- The specific provider of the treatment is out of the insurer’s network
To insurance companies, it does not matter that a doctor has recommended a treatment or that it may save the patient’s life. All that matters is that a cancer treatment may be expensive and will hurt the insurance company’s bottom line. Patients are already facing a tough battle in their fight against cancer. Unfortunately, they may also be forced to fight another battle: getting their insurance company to authorize payment for the treatment of that cancer.
Cancer treatments such as proton beam therapy are prescribed out of medical necessity. Presumably, they would meet the requirements for coverage under the Affordable Care Act. In a dispute with your insurer, the burden of proof may shift to you to prove that proton beam therapy is both a recognized treatment and medically necessary. Even if you can prove both with ease, you can still expect a fight on your hands.
You Can Contest the Insurance Company’s Denial of Your Cancer Treatment
Under the law, you have a right to challenge the denial of cancer treatments. Unfortunately, the appeals process takes time, and time may not be on your side when you are undergoing treatment for cancer. Nonetheless, you owe it to yourself and your family to fight as hard as you can for all the necessary and required treatments. Before filing your appeal, you should closely review the exact language of your health insurance policy because recent changes to federal law allow for policies that are less comprehensive in nature. In addition, you can and should consult an insurance coverage lawyer during the administrative appeals process.
Before you appeal your insurer’s decision to deny your cancer treatment, you should take several steps that can increase your chances of success, including:
- Gathering documentation that conclusively shows that the treatment is medically necessary
- Compiling additional medical records that detail your medical history and the prior course(s) of your treatment(s)
- Contacting your medical providers to help obtain supportive evidence of medical necessity
- Consulting with an insurance lawyer who can advise you on the appeals process
Insurance companies are required to offer an internal appeals process wherein you can contest the denial of benefits. However, without legal representation, the internal appeals process can become a rubber stamp of the initial decision that was made. Insurance companies rarely take an objective look at their own decisions, even though there may be legal consequences for decisions that violate the law.
You Can Take Your Case to Court if Necessary
There is an additional external check on the conduct of insurance companies. You can always take your insurance company to court and file a lawsuit to compel it to cover your cancer treatment. In the meantime, you would need to retain legal counsel and go through the entire court process and win your case. A court would provide an objective review of whether your cancer treatment would be required under federal law.
In addition, state law also serves as a constraint on an insurance company’s behavior. If the insurance company has unreasonably denied your coverage, it could be subject to a bad faith lawsuit. Further, if there are many people who have had the same treatment denied, a class action lawsuit against the insurance company may even be possible. For example, Aetna recently settled a class action lawsuit alleging that it wrongfully denied cancer treatments. A class of 142 patients who were wrongfully denied proton beam therapy treatments received a total of $3.4 million.
In another case, a judge lambasted United Healthcare for its “immoral and barbaric” conduct in denying coverage for proton beam therapy treatment. The judge, who was himself a cancer survivor, stated that “it is undisputed among legitimate medical experts that proton radiation therapy is not experimental and causes much less collateral damage than traditional radiation.”
You can and should fight back when your insurance company has wrongfully denied your cancer treatment. Not only can you legally force it to cover your treatment, but you may win additional damages in court. Also, fighting back could lead to negative news headlines for insurance companies and cause them public relations and reputational nightmares. An experienced insurance claims denial attorney knows how to leverage the court of public opinion to help support your legal battle against your health insurance company.