Last Updated on 13 February 2020

Compare Health Insurance Limitations: Experimental Treatments

It is vital that you know how some common limitations and your health policy interact.  This can be especially relevant when you compare private health insurance while searching for a new policy.  Experimental treatments can certainly be a limitation to consider.

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A Tricky Subject

Experimental treatments and the health insurance community are not separate topics, and are definitely not without controversy.

Patients who are facing serious injuries or genetic defects may approach experimental surgeries as the difference between being disabled and leading a higher quality life.  For the terminally ill, there is a rapidly closing door to life-saving treatment.

Of course there are plenty of other examples.  It may be the case that there is a new and effective “experimental treatment” that only has that label due to its recent launch in the health care community.  Some treatments are simply not widely accepted in the medical community yet – or have met resistance from health insurers.

Experimental Treatments and Your Health Policy

Are experimental treatments covered on your policy? This can be a difficult question to answer.

While your insurer may be better than others, it may simply be that experimental treatment claims are assessed on a case-by-case basis.  That is, some may be accepted and others may not.  Your policy will not outline every possible treatment – that would be quite impossible, of course.

Generally speaking, experimental treatments can be excluded or only covered partially.  It is wise to get a general idea of the dynamics that can be involved here.  Contact your insurance professional to help explain your insurer’s stance on it, and to perhaps guide you in such a discussion.

Appealing for Experimental Treatment Cover

Perhaps you’ve made a claim and it has been denied, due to it being classified as an experimental treatment.  You do have some recourse if you are such a situation.

You should first appeal to your health insurer.  Unless this initial step is waived per an agreement, you’ll need to do this before moving on to any other appeal.  You may have the option of expediting the appeal, especially under the direction of your health care provider, or if you are undergoing treatment currently.

If the decision is upheld, you will be able to make an external appeal, which is conducted by an independent external review organisation.  Keep in mind that there can be deadlines, such as a common one of 45 days following the denial of the first appeal.


It can be a tricky situation with experimental procedures and your health insurance plan.  Many times decisions are made on a case-by-case basis, which may not do much to clear up matters for you right now.

If you may be undergoing a treatment that is new or rare, it is best to speak to your insurer beforehand.  This can help you avoid any unfortunate surprises when a claim could be denied.

You should certainly keep this kind of common limitation in mind when looking for policies.  Get to know your insurance policy to realise how this could come into play.


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