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What recourse does the patient have with the health insurance carrier? A patient is...

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What recourse does the patient have with the health insurance carrier?

A patient is diagnosed with degenerative disk disease and is seeking treatment for chronic, acute pain. A spine surgeon recommends a spinal fusion to relieve the patient's unrelenting pain. This surgical procedure is considered experimental and is denied by the utilization review of the patient’s health care insurance.

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Unfortunately, most providers of health insurance plans--both private and corporate--build into their policies a "carve out" for any procedures the insurance providers consider experimental.  In other words, their policies stipulate that they are not required to cover medical procedures or medications that have not been classified as approved treatments for a particular condition.

Patients who cannot afford to pay for experimental procedures are therefore forced by economics to use procedures that may not be optimal but which are paid for under the insurance providers' plans.  In many cases, procedures that are considered experimental today will become approved procedures over time, but the timing, of course, may be too late for many people.  The solution to this dilemma for many people is to seek medical care in other countries where the expense of an experimental procedure might be significantly less than in the United States, for example.

Fortunately, in many cases, even though the optimal treatment might be classified as experimental and therefore unobtainable under an insurance plan,  approved alternative treatments will often provide some level of relief.  But from a physical and psychological standpoint, the patient still suffers because the administration of health care in this country is relatively inflexible and behind the evolution of medical procedures.

In sum, then, most patients trying to use experimental procedures under existing health care insurance laws have no recourse unless they can make the case that there is no approved alternative--and even then these patients may not succeed.


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