My sister has multiple sclerosis and is in chronic pain. She has received numerous prescriptions from her physicians to go to a pain management clinic. However, her insurance will not approve it. It breaks my heart to see her suffer like this and her insurance company doesn't care. Does anyone have any suggestions on how to get through this bureaucratic nightmare?

D.N.

Multiple sclerosis is an indiscriminate disease that afflicts people and robs them of so many abilities. There is much that medical science has to offer those with MS, but even more that we still have to learn on order to combat this disease. Much of the care provided by physicians is palliative in nature, meaning that such care does not alleviate the symptoms as much as it is intended to help the afflicted live with the effects of the disease. Such is the nature of pain management.

Your sister's physician has advised her to undergo pain management, but her insurance company won't pay for the treatment. Before you assume or conclude that this simply means that the insurance coverage is treating your sister unfairly or that this is a bureaucratic issue, perhaps it would help to understand the difference between recommended medical services and covered services.

An insurance policy is a contract between the insurance company and the policyholder. As long as the policyholder pays the premium, the insurance company will provide the coverage stated in the contract. Much of the coverage in any insurance contract is broad in nature. For example, an insurance policy may state that it will pay for visits to a doctor's office, hospitalization, or outpatient surgery. In addition, however, some insurance provisions are specific in nature, naming certain kinds of treatments and services. Finally, there are insurance provisions that specifically exclude certain medical services. An insurance contract does not limit the kind or amount of medical care that a person can receive. It only limits what the insurance policy will pay for.

One more thing about coverage: insurance contracts normally include a clause pertaining to medical necessity. This means that the insurance company reserves the right to have its medical director make a determination about the appropriateness of a recommended medical service. This is a sort of second opinion the insurance company performs to make sure that unnecessary, questionable or even harmful services are not performed.

Most likely, your sister's insurance company has determined that pain management is not covered by her policy. From your question, it is unclear whether there are any circumstances other than the fact that pain management is not a covered service. It is unlikely that such a recommendation would be subjected to a medical necessity determination.

An important first step would be for your sister to call her insurance company and ask the simple question of whether pain management is a covered service and, if so, why the company will not pay for it in this case. If the answer has to do with medical necessity, then she should appeal the decision on the basis of her doctor's recommendation.

If the answer is that it is not a covered service, your sister has little choice but to decide whether pain management is important enough to pay for out of her own funds. There are many kinds of services not covered by insurance. This means that we are often faced with a financial decision when seeking medical care -- we must determine whether or not it is worth the cost. If your sister decides that pain management is worth it, she can shop around for a good price or ask for a discount as a cash payer.

It may seem unfair for the insurance company not to pay for the pain management, but the reason may be that it is simply not covered.