Would my mom have any legal recourse against an insurance company that is refusing to make a life-saving treatment drug available to her?

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Would my mom have any legal recourse against an insurance company that is refusing to make a life-saving treatment drug available to her?

She has a rare cancer and her oncologist says that this drug could her assist with tumor shrinkage.

Asked on June 19, 2013 under Malpractice Law, Missouri

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 8 years ago | Contributor

If your mother believes that the insurer is violating its obligations to her under the policy, she could sue them for breach of contract (since an insurance policy is a contract), seeking either to force them to pay for/provide the drug or else for reimbursement of its cost (within policy guidelines) if she pays for it herself. The issue is whether they are violating the guidelines in the policy, which generally have to do with such things as whether the treatment is accepted or still experimental--while you mother needs to look at her specific policy, its common for insurers to not be required to pay for experimental or unproven treatments, for example.The insurer has to pay for anything the policy requires it to--but does not have to pay for anything not required by the policy or specifically exempted by the policy.

You mother may wish to purchase the drug herself and seek reimbursement later--court cases take time, and it may be unwise to let the cancer grow/spread while fighting the insurer.


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