Medical Necessity in Florida Health Insurance

Let an Experienced Miami Insurance Claim Lawyer Help

Oftentimes, people acquire health insurance coverage thinking that they can rest easy knowing that they won’t have to worry about their insurer “paying out” in the event of serious illness or injury.  This is unfortunately not the case in reality, however — insurers are incentivized to avoid acknowledging coverage in borderline cases, and they may write in ambiguous terms and provisions to give themselves the opportunity to deny otherwise legitimate claims.

Nowhere is this more of an obvious problem than with alternative medicine and experimental medicine treatment options.

Simply put, health insurance policies do not cover every possible type of treatment that you could receive.  Instead, they define the borders of coverage with a term: “medical necessity.”  If treatment is not medically necessary, then it will not be covered by the policy.

This can lead to some adverse results.  Even if you receive alternative medicine treatment that significantly benefits you and improves your quality of life, your insurer might decide that it was not “medically necessary” and may deny coverage, putting you in a financially vulnerable position.

Here at Ver Ploeg & Marino, P.A., our team is experienced in handling these nuanced coverage issues in the healthcare context.  We understand just how frustrating it can be to not have your insurer be an ally during such a vulnerable time — and we’re ready and willing to hold them to their promises.  Contact an experienced Miami insurance claim lawyer at our firm for guidance on how to proceed.

Let’s take a closer look at the issues.

Alternative Medicine

Alternative medicine is becoming increasingly popular as a supplement to traditional medical treatment.  For example, patients may seek chiropractic aid for spinal problems or acupuncture remedies for chronic pain issues.

Though alternative medicine is still not accepted as an exclusive remedy for serious medical problems, it is now widely accepted as a supplemental treatment.  Some health insurance plans explicitly allow for coverage with respect to chiropractic treatment, or acupuncture treatment, but explicitly reject coverage for certain other alternative medicine options.

Generally speaking, however, alternative medicine does not fall within the definition of “medical necessity” in most policies.  The key issue is that most alternative medicine does not have extensive efficacy data on which the insurer can rely when making the determination that it will resolve the patient’s illness or injury.  Those few alternative medicines that do have such data may be explicitly covered.

Of course, some alternative medicine is sufficiently well-supported by the evidence in the medical literature that you should argue for coverage if the insurer denies it.  For example, if your plan does not cover massage therapy for pain/mobility issues, then you may be able to show that it is cheap, effective, and reasonably safe to treat your conditions (and you can introduce the testimony of your physician or other professionals to support your arguments).

Experimental Treatment

Experimental treatments are experimental for a reason — their efficacy and safety are not always certain.  In the alternative, they may be too expensive to distribute to the general public and are thus made available only in very limited circumstances.

Despite these concerns, experimental treatment may be your best bet if you are suffering from a severe/chronic illness or injury, and have no other options for recovery.  You and your healthcare provider may come to the conclusion that experimental treatment is a risk worth taking.

But that’s not the end of the calculation.

If your health insurer is unwilling to cover the cost of treatment, you may not be able to move forward.  See, insurers will take advantage of the uncertainty of experimental treatment by arguing that the treatment is too dangerous, or is simply not guaranteed to “work” with respect to the illness or injury at issue.

The key in establishing medical necessity under such circumstances is to introduce evidence that the treatment is highly effective in treating the particular illness or injury that you are suffering from, and that there are no other reasonable alternatives.  If your illness is otherwise untreatable, for example, then even an expensive, risky experimental treatment could potentially be covered.

Every Policy is Different

Healthcare insurance policies vary quite significantly from plan-to-plan, and this extends to definitions of “medical necessity.”  While one plan may expressly describe the treatments that are medically necessary for particular illnesses, another plan may provide a broader definition giving more discretion to the patient and healthcare provider to come up with a personalized treatment plan.

When providing a broader definition, the insurance plan may reference a number of different factors to be considered in evaluating the “medical necessity” of a particular treatment and whether it qualifies for coverage under the plan — this may include cost, efficacy, safety, and more.

Given the variety (both in terms of provisions and the ambiguity of various contract terms), it’s critical that you consult with a qualified attorney for guidance on how to navigate this complex area of law.

Contact Our Miami Insurance Claim Lawyer Today

Ver Ploeg & Marino, P.A. is a Miami-based insurance litigation firm, with a focus on providing client-oriented legal representation and achieving significant results — whether through administrative challenges, settlement negotiations, or trial litigation.

Over the years, our team has developed a trial-ready approach to navigating insurance disputes.  This approach has brought us significant success.

Unfortunately, health insurers are too willing to deny claims even when policyholders are at their most vulnerable.  This can shock and surprise policyholders who may not fully understand why their claims have been denied.

We’re here to help.

If you’d like to speak to a seasoned Miami insurance claim lawyer about your dispute, we encourage you to contact us to schedule a consultation at your earliest convenience.  We look forward to speaking with you.

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