Can Insurance Deny Cancer Treatment?

Health plans* are required to contribute to the cost of your cancer treatment. As a cancer patient, you have the following rights under the Affordable Care Act:

  • If you meet the criteria and choose to participate in a clinical trial, your health plan is required to assist you with the usual costs connected with approved research trials. A clinical trial may aid in the development of new cancer treatments.

Why would insurance deny a cancer treatment?

Even if your doctor suggests a certain test or therapy as the best option for you, your insurance company may deny it. Denial may be based on whether the prescribed treatment is medically essential, whether the proposed treatment is experimental or investigational, or whether less intensive or invasive treatments have been attempted first and failed. Insurance companies have established rules and regulations regarding the standard of care for treating specific tumors, but these standards can soon become outdated.

Can you be denied insurance for cancer?

Because of a pre-existing health condition like asthma, diabetes, or cancer, health insurers can no longer charge you or your child extra or deny coverage. They are also unable to limit benefits for that disease. They can’t refuse to cover therapy for your pre-existing ailment once you get insurance.

Can you be denied Chemo?

If you’re like a lot of cancer patients, the mention of chemotherapy conjures up images of weeks of acute nausea and vomiting, diarrhea, tiredness, and temporary hair loss.

These stereotypes regarding chemotherapy aren’t totally correct. Many cancer patients endure some short- and long-term side effects from chemotherapy, while others have very few. Treatment for cancer is improving and evolving at a rapid pace. We now have a far wider range of chemotherapy medication alternatives than ever before. These therapies can be used in conjunction with one another or with other cutting-edge treatments, so they could be just one part of your cancer treatment plan.

Chemotherapy medications do not all have the same risk of side effects. To help patients avoid and manage potential side effects, more (and better) drugs and supportive therapies are now accessible. Many patients are astonished to learn that not everyone loses their hair, and that some people feel better after commencing chemotherapy if the cancer regresses.

Is it possible to decline chemotherapy? Yes. Your doctor will provide what he or she believes are the best treatment options for your specific cancer kind and stage, taking into account your general health, but you have the final say in your care.

This page tackles the following topics to help you make an informed decision about the advantages and hazards of chemotherapy:

What should you do if your health insurer denies medical treatment or coverage?

You have the right to appeal your health insurer’s decision and have it reviewed by a third party if it refuses to pay a claim or terminates your coverage.

You have the right to request that your insurer reconsider its decision. Insurers are required to explain why they refused your claim or terminated your coverage. They must also inform you of your rights to appeal their decisions.

Note: See Can I appeal a Marketplace decision? if you want to challenge a Marketplace decision about eligibility or tax credits.

Why do insurance companies deny treatment?

When health insurance companies deny otherwise covered claims, one of the most common grounds given is “There is no medical necessity.” To be covered by most health insurance, a procedure must be medically required to treat an accident or sickness. Medical need, on the other hand, can be a hazy idea. Is it strictly required to choose between two feasible treatments if one is both more expensive and better (more effective, more likely to cure)? “Is it absolutely necessary?” In most cases, if your doctor determines that a procedure is necessary for therapy, your insurer is unlikely to disagree. They may attempt again, and you have the right to defend yourself.

Even within this framework, health insurers have a history of taking arbitrary shortcuts. A provider, for example, can decide that anything that counts as “By definition, “cosmetic” surgery isn’t medically required. However, some illnesses necessitate treatments that would otherwise be considered cosmetic. Lipedema, for example, is a painful and debilitating illness that can be treated with liposuction. Some insurance companies try to refuse liposuction under their umbrella policies “Even when it is required to address a condition that can leave a person incapacitated and in chronic pain, the “no cosmetic treatments” rule applies. If your claim was unfairly refused as not medically essential, speak with an insurance denial attorney.

Is cancer considered a pre-existing condition?

A “pre-existing condition” is a medical ailment or injury that you have before starting a new health-care plan. Pre-existing health issues include diabetes, COPD, cancer, and sleep apnea, to name a few. They are usually chronic or long-term in nature.

How are pre-existing conditions determined?

A pre-existing ailment is one for which you had treatment or obtained a diagnosis before enrolling in a new health plan. Prior to 2010, when the Affordable Care Act (ACA) was passed, an insurance company would analyze your enrollment application and, if they discovered you had a pre-existing condition, might deny you coverage or offer you coverage at inflated prices.

Because of the Affordable Care Act, it is now illegal for health insurance companies to refuse coverage or raise rates based on a pre-existing condition.

What are some examples of pre-existing health conditions?

Many types of cancer, diabetes, lupus, epilepsy, and depression are examples of chronic illnesses and medical problems that may be considered pre-existing. Pregnancy is also considered pre-existing and chronic prior to enrollment, however less serious diseases including acne, asthma, anxiety, and sleep apnea may still qualify.

Can I be denied health insurance if I have a pre-existing condition?

No, your insurer cannot legally reject you coverage or charge you more premiums because you have a pre-existing condition if you have been enrolled in a plan after 2010.

The Affordable Care Act of 2010 made it illegal for insurers to deny coverage or charge exorbitant premiums to anyone with pre-existing diseases. Furthermore, if your health changes and you develop a chronic medical condition while enrolled in a health plan, your insurance carrier is prohibited from raising your rates as a result of the medical condition. Annual premium hikes, on the other hand, may apply to your plan for various reasons.

If you’re enrolled in a plan that began before 2010, though, you’re in a “grandfathered plan.” Due to a pre-existing condition, these plans have the ability to cancel your coverage or charge you higher prices.

If you’re looking at different insurance options, you should be aware of any prospective changes in health-care legislation that could affect how pre-existing conditions are covered.

Is pregnancy considered a pre-existing condition?

No. You cannot be denied coverage or charged more if you get pregnant before enrolling in a health plan. Pregnancy and delivery coverage begins the day you enroll in a plan.

Is there health insurance for pre-existing conditions?

The concept of a pre-existing condition is no longer used when choosing a health plan. If you have a medical condition at the time of enrollment, a health insurer cannot deny you coverage or boost your premiums. If you have a chronic or pre-existing medical condition, however, some health plans may be a better option for you than others.

If you require regular medical care, surgery, or treatments, for example, a plan with a little higher monthly premium and smaller deductible may give you with the coverage you require while also allowing you to budget more predictably.

Could my health plan have a pre-existing condition waiting period?

No, medical insurance do not have any waiting periods, including for pre-existing conditions.

Consider your medical requirements before selecting a health plan. If you have a chronic or continuous medical condition that necessitates more frequent treatment, the type of plan you choose may be influenced by your needs, but you cannot be denied coverage or paid more because of a pre-existing condition.

Can I be denied health insurance because of a pre-existing condition?

Yes. Health insurance providers can’t refuse to cover you or charge you more because you have a “pre-existing condition” — a health problem you had before the start date of your new health coverage — under the Affordable Care Act. They are also unable to charge women a higher rate than men.

Only grandfathered individual health insurance plans, which you buy yourself rather than via an employer, are exempt from the pre-existing coverage provision. Pre-existing conditions are not required to be covered.

Does chemotherapy qualify for short term disability?

Cancer patients frequently face financial damage. When a patient has high medical bills that aren’t covered by insurance or has less income because they can’t work full-time, this is what happens. Debt and bankruptcy are frequently the result of financial toxicity. Short- and long-term disability are options for cancer patients who are facing financial difficulties.

You must be unable to work due to your disease, its treatment, or its side effects to be eligible for short- or long-term disability. Cancer may be a qualifying condition depending on the severity and course of therapy.

If you have any doubts regarding whether you are eligible for disability insurance, speak with your oncologist social worker.

Kristine Tarter, an oncologist social worker at Marshfield Clinic Health System, said, “Your oncology social worker can equip you with the tools and education to know how to apply.”

What happens if you can’t tolerate chemo?

A person may wish to discontinue chemotherapy for a period of time or permanently. This could be due to negative side effects, a lack of effectiveness of the treatment, or other factors.

Anyone thinking about quitting should consult their doctor beforehand. They will outline the possible next actions and assist the individual in making the best decision possible.

Other options

Palliative care is an option if cancer does not respond to chemotherapy, radiation therapy, or other treatments.

Palliative care can be combined with other treatments or provided on its own. The goal is to improve people’s quality of life.

Hospice care may also be beneficial if a person’s treatment is no longer effective or if they have advanced cancer.

A healthcare team will devise a strategy to help manage all areas of the person’s care while also ensuring their comfort.