Insurance providers often consider new drug therapies as being experimental in nature.
Normally, health insurance plans will pay for most preventative medical care including screening for diseases. In most cases, insurance pays for the treatment of diseases, except when a health plan specifically excludes coverage for a pre-existing medical condition. Although insurance plans traditionally have not been willing to pay for experimental medical treatments, with advances in medical research, the tide is slowly changing.
Denying Treatment
Although clinical trials and experimental medical treatments have the potential to increase both the length and quality of a person's life, insurance companies often refuse to pay for untried and costly medical procedures. With new treatment therapies constantly evolving, insurers find themselves in the position of coming up with ways to cut rising health insurance costs. Consequently, experimental treatments are often among the first medical expenses an insurance provider denies.
Insurance Guidelines
Despite medical research making the availability of experimental treatments more common, few insurance companies will pay toward the treatments. For this reason, it is essential to read the details of your health plan. Insurance providers have different guidelines governing what they do and do not cover. Some plans may partially cover the cost of a treatment or drug that another health plan won't pay toward at all. In extraordinary circumstances, if you can prove to your insurance company that an experimental treatment or drug is effective in your particular case, the company may pay for it.
Essential Factors
When deciding if a treatment is experimental, an insurer considers certain factors. The company may take into account whether there is a lack of alternative treatments, if there is published research on the safety and effectiveness of the treatment and for how long the treatment would be prescribed. Other factors may include whether the treatment is FDA approved, evaluation of the research protocols used and if the treatment is being used as a last effort to save your life.
Texas-Aetna Settlement
One of the major provisions covered by the Texas-Aetna Settlement was expanded coverage for experimental treatments. The settlement resulted in further managed care reform by adding the state of Texas to a list of jurisdictions that require health insurers and managed care organizations to sometimes pay for experimental treatments. While similar lawsuits are opening this door to more patients, to qualify for coverage, a person's physician must certify that standard treatments have failed to be effective and are not expected to be successful in combating the disease. Even if there are no other conventional therapy treatments available, there must be scientific evidence that the experimental treatment has a reasonable chance to succeed. Medical journals and other peer-reviewed literature must suggest that the experimental treatment is more likely than standard medical treatments to benefit the patient.
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