Paying for Cancer Care: What to Do When Insurance Says No

What to do when the treatment your doctor recommends isn't covered by insurance.


Last updated: February 08, 2010
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I can't tell you how often I hear the same story from friends, colleagues, or from readers here at Caring.com. It always follows the same outline: The oncologist, working as diligently as possible to come up with an effective treatment plan, tells a cancer patient and her family that a particular treatment is the best option. But the treatment is expensive, and the insurance company refuses to cover it.

Sometimes the reason given is that it's not the "standard of care," meaning someone at the company has looked at a list of treatment protocols and doesn't see this one listed. Sometimes the treatment is deemed "experimental," although doctors have plenty of evidence that it works. Sometimes the reasons behind the decision are even murkier, such as in this great "rant" (his term, not mine) by oncologist and blogger Doctor David, who describes a case in which the insurance company's wording was that "there was no evidence" the treatment he'd selected was "useful in this disease."

Luckily for this particular patient, Doctor David is one of those doctors who really cares, and he cared enough to do a search, round up almost 500 articles documenting the usefulness of the scan he'd recommended, and send a selection off to the insurance company.

Of course, he was justifiably angry that the insurance company's physician reviewer, who, as he points out, isn't even an oncologist, would second guess the treatment that he, the expert, recommended for his patient.

Reading this post, I was reminded of so many moments when my family and I sat around the kitchen table exchanging epithets about my dad's insurance company because they'd refused to cover the cost of getting a second opinion and denied him coverage for radiation treatments to prolong his life because his diagnosis was considered "fatal" anyhow. How, we'd ask each other bitterly, would they feel if it were their father who might gain several months of life?

So I thought it would be a good time to revisit my tips for getting the insurance company to pay up. A quick review:

1. Know your policy well. Pore over the booklet you likely have in a file somewhere, that details what your insurance policy does and doesn't cover, and what the co-pays and other charges are for different procedures. If you have questions, call and ask, and make sure the representative goes through each topic thoroughly. Many insurance companies also now have websites you can use the same way, so check online as well. The booklet or website should also contain instructions for how to appeal a decision, and you'll be needing those as well.
2. Ask for help from your employer or insurance agent. If your insurance is through your job, enlist help from your human resources department, since the company as a whole has more leverage than you do as an individual.
3. Appeal, appeal, appeal. Just as Doctor David did for his patient, this is what you'll need to do for your family member -- in partnership with the doctor, if possible. Have the doctor write a letter explaining that she ordered the treatment and why it was necessary. If the grounds for refusal to pay was that the treatment was "experimental," enclose articles or studies showing that that procedure is being used elsewhere to treat the condition it was recommended for.
4. Get everything in writing. As much as possible, use e-mail and letters when dealing with an insurance company, because that gives you a written record of what was said. If you call, take thorough notes, and ask at the beginning of the conversation for a direct number for call-backs if necessary. Also ask the person you're speaking with to keep a record of the phone call and put it in your file.
5. Keep records of names and titles. Get a first and last name and title every time you have a phone conversation with anyone at either the insurance company or your doctor's office.
6. Keep all records for three years. Don't throw anything out, even after a claim is paid. You never know when a new but similar issue will come up, or whether you'll discover down the line that another mistake was made.

Sometimes it's also necessary to enlist the help of a lawyer, if nothing else to draft your letters on official letterhead. We'll tackle this topic in a future post. In the meantime, if you have stories to tell or questions to ask about making insurance companies pay up, please share.

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7 Comments So Far. Add Your Wisdom.

over 3 years ago

Hi 65522, Thank you for your question. Sorry to hear about your friend's father, that sounds like a really rough situation. One place you may be able to find an answer is in our Ask & Answer section: http://www.caring.com/ask Good luck, I'll keep your friend's father in my thoughts. -- Emily


over 3 years ago

My friend's dad has cancer and the insurance is refusing to pay, is it legal to just let him die. What should I do??? HELP!!!


over 3 years ago

Many cancer patients aren't aware of an additional option for obtaining funds for treatment. It's called a "viatical settlement". Through a viatical settlement, you can sell your life insurance policy to a licensed financial institution for a lump-sum of immediate funds. The benefits are typically tax free and can be used however you please, including to pay for medical expenses, living expenses, or simply to enjoy life. Please contact me or visit my company's website at www.mypolicyoptions.com to learn more. Our company has helped countless cancer patients obtain funds in their times of need. While you're fighting cancer, we'll be fighting for you.


over 4 years ago

Honestly, if one were to look at medical insurance as an industry, it has been highly effective at making sure that their assets are protected before they go ahead and cover anyone. The only way that you can fight an medical/health insurance company is through the legal route. Most people end who are not treated fairly end up loosing faith and give up on the situation, simply because legal help is priced so far out of their range that they simply just don't have access to the justice system. For those of you who are being taken for a ride by a medical insurance company, I would take a look at the following information about a company that is helping millions of people across the U.S take a stand against situations like this. Follow the link for more information if you wish. http://www.prepaidlgl.net/


over 4 years ago

The only patient solution to such a health care mess is for patients to seek the expertise of experienced organizations such as Cancer Care Denial Appeals. Their website is most helpful and has a good list of resources. www.cancercaredenial.com


over 4 years ago

This is your real "Death Panels".


over 4 years ago

Thank you, VERY true. It makes my blood boil to think how many people to not challenge their insurance company's bad decision, whether out of intimidation or exhaustion or from simply not knowing that they CAN challenge it. And what is worse, counting on their customers' lack of sophistication is part of the insurance companies' business plans.


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