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Has anyone else had an insurance claim denied due to study drug?

We are treating a 4yr old with cancer and the insurance company has denied the claim because he is on a study drug. They were not being billed for the drug only for the hospitalization (5 rounds 4 days each). Our hospital will fight them and probably win, but I want to know if this is a new limitation on health insurance or an isolated incident.

Public Comments

1. It's not new, most insurance companies routinely deny 'experimental' drugs and treatment as 'medically unnecessary'. Insurance companies are limited to documented scientific evidence that supports the use specific drugs to treat the specific cancer. What type of cancer and what is the new drug being used? Insurance company policies vary too, what type of insurance do you have? There are definitely ways around this so do not become discouraged yet. Keep calm when you communicate with them, and I know this is hard to do because it is your babies life they are so casually tossing around. From what you have written I suspect the insurance has a glitch in it for not covering the hospitization. Call them and ask them to re-process the claim. Better yet, if you have a case worker at the insurance company, call them to see if they can help straighten this out. If you do not have a case worker, you can request one. They can't change policy but they can make sure the claims have been made out and processed appropriately. If they continue to deny coverage than you may appeal the decision. You can appeal over the phone or by letter. Whatever you do keep good records. Write down date, time, who you talked to and the result of the conversation. Keep a binder handy and document everything. If the insurance denies coverage a second time, write another letter and while you're at it contact your states insurance bureau. If you need to write or call your local state representative, congressmen, and/or senators. Keep communicating with the insurance company to find out exactly what the denial is all about. At some point you may have the right to ask the insurance company to provide an 'expert in your daughters type of cancer' to review the denial. When that happens . . usually the insurance company will pay the claim based on 'compassion'. Whatever you do, do not give up on this. If you have insurance and the policy has covered hospitalization and other treatment in the past than they need to be held accountable. Be persistent and firm with them, they're suppose to be working for you. Good luck.