Child With Cancer Successfully Wins Challenge Against Experimental Exclusion

A decent portion of my and my wife’s ongoing war with Aetna has to do with their attempts to deny my wife’s claim on the grounds that her treatment is “experimental and investigatory” and doesn’t show sufficient promise to meet the exception to that clause.

So, this article at Business Insurance warms my heart just a little.  It’s nice to see any insurer’s over-use of that exclusion overturned.

A health insurer wrongfully denied coverage for a specialized chemotherapy treatment for a child with cancer, according to the Wisconsin Supreme Court. [...]

The Supreme Court ruled the insurer’s termination of benefits decision was made despite an external review agency’s finding that the requested treatment met the standard of care and was medically necessary and its recommendation that the treatment be approved. The insurer also did not provide a sufficient and adequate explanation for the termination of benefits.

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