What Do You Mean It's Not Covered: How the Policy Defines "Regular and Customary"

Benefits are often limited to the "regular or customary charges" for similar services in the area where care is given, because costs vary by geographic area. This helps to discourage excessive charges for services. A major issue that follows from this language: whether or not a medical procedure that an insurance company calls "experimental" qualifies as regular or customary. It usually doesn't. And big disputes usually follow. A protracted lawsuit, still going on in late 1994, pitted the survivors of a breast cancer victim against a health insurance company that limited its coverage from treatments that had anything to do with the loosely-defined term "medical research." Kenneth Fuja v. Benefit Trust Life Insurance Co. also illustrates how regulators and courts of law interpret policy exclusions. Grace Rodela Fuja, a thirty-seven year-old woman suffering from breast cancer, sued her insurance company, Benefit Trust Life Insurance Co., for refusing to pay for a "high-dose chemotherapy treatment with autologous bone marrow transplantation" (HDC/ABMT). In August 1989, Fuja had been diagnosed with breast cancer and underwent a lumpectomy and a modified radical mastectomy. Beginning in September 1989, she received six months of standard-dose chemotherapy treatment. She seemed to remain in remission until February 1992, when her oncologist observed that the cancer had spread to both her lungs. From February through December 1992, Fuja responded to standard-dose chemotherapy -- but during this period her physician came to the conclusion that continued treatment with such standard dose chemotherapy offered her but a negligible chance of survival. She prescribed a regimen of HDC/ABMT.