Absolutely, the insurer could sacrifice some profitability to pay for this case, but eventually health care costs have to be rationed somewhere. I don't think any health care system can afford this level of treatment for as often as it is needed, and I don't think capping the profit in the industry solves that problem.

Also I would agree the insurer is absolutely making medical decisions with its own definition of medical necessity. But the Doctor is also making financial decisions when he recommends a drug that pays him significant consulting fees every year. There's warped incentives all over.

I look at it as Insurers generate float from upfront premium payments to invest in the market and generate returns and also cover future payouts.

Then an insurer can go about negotiating the prices of treatment with health care providers to determine payouts.

I'm genuinely curious, what countries work this way? I've never heard of it, every system has some form of rationing as far as I know.

Agreed. Medicine is one area where desperate people will understandably reach for any measure that offers some hope, but insurers can't be on the hook for everything.

The insurer is a business, its ultimate priority is the make money. Same as the hospital, the drug producer, etc. I am sure they all want to prioritize client care but that have to ration it by cost at some level.