Complaint 5 of 5 in “Experimental Treatment”

Consumer Complaint:

I have to have high dose Ketamine boosters every three weeks to help with the pain ofmy full body CRPS.  The only place I could go for this treatment at the time was at the RSD Foudation Treatment Center in Tampa, Fl. My Insurance company has not reimbursed me for any of the 8,5000.00 for the four Ketamine boosters I had to pay in full for at the time of my visit. For each booster, which is 2000.00, the insurance company is only covering 187.00. They are also staing that because it was out of network that they will be paying an even lower rate, even though High dose Ketamine is not administered anywhere in Ga. Ketamine is keeping me walking and free from the excrusiating pain of CRPS.

Insurance Expert Answer:

Based on what I found in Wikipedia, http://en.wikipedia.org/wiki/Complex_regional_pain_syndrome printed in part below, I can see several reasons for your problem. First, medical insurance policies generally expressly exclude and thus do not provide any coverage for experimental or investigational treatments. Assuming your plan is a standard plan that would seem to be your first obstacle as the Ketamine treatments you received seem to be experimental. Second, almost all plans pay very different rates for in-network and out of network treatments and procedures even when the procedure is covered. All those terms were built into the policy when you bought the policy or received it as part of your health program from your employer. There are numerous reasons why insurance plans -- private plans as well as public plans such as Medicare and Medicaid -- do not cover experimental or investigatory treatments, even where the treatment seems effective for some patients. Generally it has a lot to do with cost considerations as experimental treatment is usually far more expensive than other possible treatments, and the insurance plans do not want to find themselves in the position of in effect financing very expensive health care research. Plans pay far less for out of network treatment as part of the very financial structure of insurance plans. To induce hospitals and doctors to give them a discount, the plans promise to encourage their insureds to go \"in network.\" That's why they pay you less if you go out of network. I know this sounds unfair, but ALL insurance plans -- public and private -- design and administer their plans to hold down costs and try to match income and expenses so the costs do not go out of sight. As a nation we already are spending 16.5% of Gross Domestic Product on health care, and that huge percentage is the highest in the world and continues to rapidly increase, despite so many folks without health care. This whole issue raises major issues for our society, but every other nation does some form of rationing -- and while the Government seems to be doing something at long last to provide all Americans with at least basic health care, everybody can not get the Government or private employers or insurance companies to pay for everything.