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Chemotherapy: The Financial Aspects

If Your Insurer Refuses To Pay For Chemotherapy

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According to the American Cancer Society, offsite link Insurance companies may deny payment for chemo for any of the following reasons. The company:

  • May not be aware of new treatments.
  • May limit the selection of drugs that doctors can use for chemo.
  • May restrict payment to the uses first approved by the Food and Drug Administration (FDA).
  • May say the treatment is experimental - especially if it is given through a clinical trial.

If your insurer denies payment:

  • Appeal! And keep appealing until you get a "yes."
    • Check your policy to find out what you have to do to appeal and by when.
    • Deadlines are important. If you miss a deadline, you may lose the right to appeal.
    • Tell your health care team.
    • The health care team may have encountered a similar situation before and have all arguments ready to go to get the decision changed. Even if not, the office will be critical to the process.
    • The doctor's office will hopefully even do the work for you. If the doctor's office offers to take over the work, it's in your interest to be part of the process.
    • Even if the doctor's office doesn't do the appeal work for you, it is in the doctor's interest to help with the appeal. For instance, the doctor can help locate scientific studies which show that a particular drug is effective for your particular cancer and stage. He or she can also help provide information about what is being done in the cancer community.
    • Ask hospitals and cancer centers where the treatment will be provided to help prove why the treatment is effective for your situation.
    • Contact the pharmaceutical company which manufactures the chemotherapy drug. The company can provide information to counter the insurance company's argument. It may even have specialists who will deal directly with the insurer for you.
    • To learn more, see the Survivorship A to Z document: Health Insurance: Appeals

A last alternative may be to sue the insurance company to get it to pay for your cancer treatment. In many cases, courts have sided with patients and ordered insurance companies to pay for a patient's treatment. If this alternative is necessary, see: How To Choose A Lawyer

To Learn More

More Information

Health Insurance: Claims: Appeals

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