When Insurers Determine What Constitutes “Experimental” Treatment

Chicago, ILAnyone who watches the news knows that stories of long term disability denials are all too common. Frequently, policyholders have their insurance claim denied because they do not meet their insurance provider’s standards for “disabled” or because their condition is not covered by a policy. But what happens when the policyholder has a diagnosed condition and is offered a treatment but denied because the insurance company considers the treatment experimental?

NBC Chicago (2/28/15) reports on Amy Carbone who has Type I diabetes and a compounding issue: hypoglycemia unawareness. Hypoglycemia unawareness means Carbone’s blood sugar could drop dangerously low without her knowing about it. Without that warning, Carbone is at risk of losing consciousness in life-threatening situations, such as while driving.

Carbone was prescribed a Medtronic MiniMed 530G with Enlite - an insulin pump with a continuous glucose monitoring system that has been approved by the FDA for use. But Carbone’s insurance provider, United HealthCare, has stated that the device is unproven and has not been shown to be better than other pumps. According to NBC, the device, which is more than $10,000, is covered by other insurance companies.

Policyholders who have their insurance claims denied by insurance companies can file an appeal with the insurance company to have their case reconsidered. In some cases, they can also file a lawsuit against the insurance company. Such lawsuits have been effective at getting insurance denials overturned, especially in situations where the insurance company has been found to have violated the law.

Insurance companies have come under fire recently for allegedly refusing to cover necessary treatment for mental health issues. According to a CBS report, some insurance companies have routinely denied or reversed insurance claims for medically necessary treatment of issues such as depression and eating disorders. These denials have in some cases resulted in patients being released from the hospital too early.

One lawsuit, Shelbe Oppel v. Blue Cross Life et al (Case number BC518736), alleged that Anthem Blue Cross violated the law and discriminated against patients with eating disorders by failing to authorize treatment for patients with eating disorders. Among the allegations in the lawsuit are that Anthem’s guidelines for treatment of eating disorders are based on old references - such as a 1974 Psychiatric Peer Review Manual that is no longer published - and fail to reflect current medical standards on treatment of eating disorders.

Furthermore, the lawsuit alleges, “Anthem does not use qualified ‘peer review’ physicians, but rather compromised doctors who have serious disciplinary records, inappropriate and conflicted relationships with other Anthem peer review physicians and/or are clinically inexperienced.” The lawsuit also claims denial letters contain robosignatures bearing the names of physicians who do not review the case files.