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Healthcare insurance policies typically contain a number of exclusions, all of which are designed to reduce the risk for insurers. Some exclusions are more controversial than others, such as the pre-existing condition exclusion of most policies. Others are more ambiguous and leave a lot of room for interpretation and questions. One such exclusion is the experimental procedures exclusion.
If you or a loved one recently received a denial letter citing experimental procedures or “investigational treatment” as the basis for the decision, do not take the denial at face value. One of our experienced claims denial attorneys at Kantor & Kantor LLP can help assess your policy and its exclusions and appeal wrongful denials.
When you hear the term “experimental treatment,” you think of processes and procedures that have yet to be tested, do not have FDA approval, or which have no known success rate. However, what insurance companies mean by investigational treatment is that the treatment is highly effective.
If a treatment is effective, though, why would the insurance companies refuse to cover it? Generally, such effective treatments are very costly.
To determine which treatments to label as experimental or investigational, insurers consult with medical professionals whom they essentially buy out to attest to the “fact” that the procedures are what the insurance companies claim them to be. They then couch these exclusions in internal medical policies, which they then yield when a claimant tries to appeal an adverse decision.
The thing about experimental procedures is that, the majority of the time, they work. When insurance companies deny the payment of treatment, what they are really denying you is a cure and the opportunity to make your life better.
Our team at Kantor & Kantor LLP works to expose and put an end to unjust insurance practices. We do this by fighting claim denials and holding insurers who are guilty of bad faith accountable for their actions. Denials based on experimental or investigational procedures are particularly problematic as many claimants do not think to investigate the meaning of either term or to explore the internal medical policy. If they do think to examine the internal medical policy, they may discover that yes, their insurer was right to deny the claim.
Our team does not stop when we discover exclusionary clauses. Rather, we pick them apart and prove that they rely on outdated medical and scientific literature. We also depose the doctors who sign off on the policies and get them to, under oath, attest to the true nature of the experimental or investigational procedures. This puts pressure on the insurer to resolve and settle your claim more quickly and fairly than they would have been inclined to otherwise.
If you recently received a claim denial on the basis of an experimental or investigational procedure, do not be discouraged. Contact the insurance claims denial attorneys at Kantor & Kantor LLP for help examining the exclusionary clauses and reversing the decision. Contact our firm online or by phone today.
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