Breast Cancer and Health Insurance

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By: Rachel Scott Decker

When confronted with the challenges of breast cancer, the last thing a person needs to worry about is whether the health insurance company is going to fight payment for the treatment the doctor recommends. Unfortunately, many women are confronted with this issue, when their doctors recommend newer treatments or when the women unwittingly do not follow the proper procedure in claiming benefits.

Many health insurance policies carry exclusions for experimental treatments. Often an argument arises about whether the care the doctor recommends is in fact experimental, and sometimes, the insurance company denies payment for items the company deems experimental, which treatments your doctor has indicated are no longer experimental. This is particularly true in cancer cases where research into new treatments is ongoing.

Another issue that may arise deals with whether or not the treatment is medically necessary. Often, disagreements arise between your doctors and the insurance company about whether the treatment the doctor has recommended for you is in fact medically necessary for you. This particular problem is one of the cornerstones of the debate among people pushing HMO reform in the United States Congress and in the North Carolina Legislature.

Sometimes, an insurance company may deny coverage for the reconstructive surgery a person may elect to undergo following a mastectomy. Sometimes there may be a legitimate exclusion in the policy that excludes benefits. Other times, the company may deny benefits when a legitimate exclusion does not apply. Also, a policy may provide coverage for these procedures, but the insurance company may require prior approval before authorizing the surgery.

Some policies may require prior approval for certain benefits. This prior approval is required in a myriad of circumstances, but particularly, where the patient seeks help from an in home nurse.

When facing new procedures with their doctor, women should make sure that they or their doctors are in contact with the insurance company to secure approval for the procedure in advance. If an insurance company denies benefits, often the physician can be of assistance to the patient in providing letters or explanations to the insurance company that address the insurance company’s stated concern. This is particularly true where the company claims that the treatment is not medically necessary or where the company claims that the treatment is experimental.

If the woman is not able to resolve the issue with the insurance company by herself or with the assistance of her physician, she should seek legal counsel to ensure that the benefits to which she is entitled are in fact received. Ward Black Law, P.A. has lawyers on staff who can provide women with an initial free consultation to discuss any such issues that arise.

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