Q. My wife was recently diagnosed with cancer and went through surgery. We found a promising follow up treatment but the insurance company has denied payment because they say the treatment is experimental or investigational. We appealed and got the same result. We hired a lawyer and are just filing for external review. We contacted the Insurance Division but you appear powerless to do anything, even though you tried.
A. Thankfully, medical science is constantly developing new medicines and treatments. However, experimental or investigational treatments are typically excluded in health insurance contracts until such time as there is enough evidence to support their safety and effectiveness. You've identified an important safeguard in Oregon law to make sure insurance companies apply this exclusion appropriately: external review.
Insurers in Oregon offering health benefit plans are required to have an external review program. This means your wife's medical records and any other documentation you wish to submit may be reviewed by independent medical professionals. The State of Oregon contracts with several external review organizations which are assigned at random and are not affiliated with the state or the insurance company. There is no charge to you for this process.
Independent reviewers must base their determination whether the decision of an insurer should be upheld or overturned on expert clinical judgment, after considering relevant medical, scientific and cost-effectiveness evidence and medical standards of practice in the United States. About a third of the denials are overturned.
While we can't always get the desired result, our advocacy team is available to help when you experience difficulties with your insurance company or agent. Advocates answer questions, explain processes, and may contact the insurance company on your behalf to be sure the company is in compliance with the law and the terms of the contract. We can also help you understand the appeals process and what types of materials may be helpful to make your case. An appeals guide is available on our website: www.cbs.state.or.us/ins/consumer/appeals-guide/appeals-guide.pdf. The advocacy line is (888) 877-4894.