Mansell, Engel & Cole

Why do insurers so often deny a doctor-recommended treatment?

No reasonable person begrudges an insurance company’s efforts to maximize corporate profits, provided it does not compromise an insured’s health in the process.

After all, a coverage provider is no different than any other commercial entity in that it must do well to survive in the market place. An insurance company’s bottom line must stress profitability.

Notwithstanding that obvious truth, though, legions of individuals and families across the United States -- including in Oklahoma -- question the conduct of their insurers following instances of claim delays and outright denials. While profitability is a given, so too must be an insurer’s good-faith response to demands for action from a contractually performing policyholder.

Media stories from across the country are replete with reports of questionable insurer responses to claim requests, especially treatment recommendations made by obviously informed physicians. Insurance denial is so common in such matters that it has almost become a default response.

A recent cancer-linked story from outside Oklahoma underscores the point, spotlighting an insurer’s denial rationale that is commonly invoked.

In a nutshell, a woman diagnosed with a serious form of cancer was recommended for proton beam therapy, an increasingly recommended treatment prescribed in lieu of traditional chemotherapy. Such therapy is widely endorsed by experts nationally, including practitioners at the Mayo Clinic.

The woman’s insurer denied the treatment repeatedly. Its rationale was that the therapy is not sufficiently “evidence-based.” That language is routinely employed in claim denials, with insurers frequently insisting on a cheaper -- and, to many physicians, less attractive -- alternative.

Insurer/insured disputes are incredibly common, often leaving the latter feeling helpless and vulnerable during a time of great personal stress. In such instances, challenged policyholders reasonably questioning an insurer’s good faith can reach out for prompt and proven legal help to an experienced pro-policyholders’ insurance law legal team.

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