Will your medical insurance pay for experimental treatments?

Medical advancements such as stem cell research and genetic therapy are changing the landscape of modern medicine. While wherever possible your specialist will opt for an established treatment plan, on rare occasions they may feel that an innovative therapy can offers you the best chance of recovery. Wherever possible patients will be offered a choice by their specialists, with a detailed discussion and explanation of the pros and cons surrounding both options. However, many people who resort to experimental treatments and therapies have no other choice. The hope that a breakthrough treatment can help them on the road to recovery is quite simply a last resort before palliative care.

Your insurer will review all requests for experimental treatments on an individual basis

It’s important to stress that I can’t provide you with any concrete answers surrounding whether a specific treatment will be covered by your insurer. While I can explain the guidelines generally operated by your insurer, all claims are assessed on an individual basis. If you find yourself in the position where you are offered experimental treatment it’s best to ring your insurer as soon as possible. These claims will nearly always need to be escalated to internal medical personnel, so the sooner you get the process moving, the sooner a decision will be reached.

Generally your insurer will not cover you for any treatment unless it meets the following criteria:

  • Established and proven within common practice in the UK – In practice this generally means that it is approved by the National Institute of Clinical Excellence (NICE) for use in the NHS.

  • The treatment is supported by peer reviewed clinical evidence that demonstrate it has successful outcomes.

  • It is practised widely by UK specialists and regarded as acceptable clinical practice.

These stringent guidelines mean that very few experimental treatments are covered by UK medical insurers in full. However, in the interests of fairness even if a treatment is considered experimental large insurers such as Aviva and Bupa will still pay for the lowest cost of either:

  • the experimental treatment itself; or

  • an equivalent established treatment which is usually provided for this condition.

  • HOWEVER if there is no established treatment currently available then your insurer will be unable to offer any financial contribution towards your treatment. Also if an experimental procedure is unsuccessful your insurer will not pay any further costs towards the treatment of the condition itself, or any other condition which develops as a result of undergoing the experimental treatment.

What if my treatment is denied?

If you’ve been told by your insurer that they won’t cover your treatment, there are a number of options to try and get your insurer to pay up.

  • Firstly speak to your specialist and see if there are any other alternatives to the proposed treatment, it could be that your insurer will cover one of these options.

  • Follow the complaints process and appeal the decision. You may need to provide medical evidence from your specialist, but this is worth pursuing as often decisions are overturned.

  • Make a record of your dealings with your insurance company. All calls are recorded and sometimes a procedural slip up such as not explaining the correct terms and conditions or procedure can mean your insurer feels it is ethical to approve your treatment.

  • If the internal complaints process is exhausted you can take your complaint to the Financial Services Ombudsman to look into. They will investigate your complaint and if your insurer has failed to behave according to the principles of the FSA they will demand redress for you, meaning your denial could be overturned.

  • If all else fails as you have a contract with your insurer you could seek independent legal advice to see if there has been a breach of contract. The English legal system is cracking down on contracts filled with ambiguous language surrounding exclusions across the insurance industry.

Unfortunately appealing a decision takes time and if urgent medical treatment is required a hold up with your insurance can cause considerable stress. While it’s possible to opt for the NHS route, many experimental treatments will not be covered, meaning you could be left with no choice but to self fund or opt for a more established treatment.

Like this guide? Share it: