Health Insurance Companies Illegally Deny Treatments and Services

Medicine and healthcare has evolved: treatments and services available today were non-existent a few decades ago. But health insurance has also evolved, often to our detriment. Increasingly, bad faith insurance lawsuits are filed against Health Insurers denying medical claims. Insurers such as Anthem & Blue Cross/Blue Shield require increasingly high co-pays, while they deny valid claims because the treatment is “experimental” or “investigational” or “not medically necessary”. If your health insurance company refuses to cover your treatment, you may want to seek legal help.

Read your health care policy, including the fine print. The health insurance company may have exclusions for certain treatments and/or services, even though approved by the FDA or recommended by your doctor. The insurer may say there is insufficient proof demonstrating that certain treatments are safe and effective for their intended use, making them investigational or experimental and not a covered medical benefit. Whether a particular treatment is investigational or experimental will depend on how it is defined in the health plan contract. Health Insurers often deny claims without thoroughly vetting the science behind the treatment.
  The most common reasons a health insurer denies your claim is because the treatment is considered experimental, the treatment is not medically necessary, or the treatment has not been proven to be more effective than other treatments allowed by the insurer. Your insurer must provide reasons for denying your claim or not paying your medical bill. It must also include the doctor they used and its guidelines or basis for the denial.
  United Health Care California - United HealthCare Insurance Company uses an exclusion in its medical policies for treatments it considers “Experimental or Investigational or Unproven.” The investigational definition merely requires that the treatment have approval from an appropriate regulatory body such as the FDA. The Unproven definition, however, excludes treatments:
 

• “that are determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on net health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature.”

Anthem Blue Cross - Anthem, the second-largest insurance company in the country, excludes experimental and investigational treatments, which it defines as:
 

• “any treatment, therapy, procedure, Drug or Drug usage for non-FDA approved indications, facility or facility usage, equipment or equipment usage, device or device usage, or supplies which are not recognized in accordance with generally accepted professional medical standards as being safe and effective for use in the treatment of an illness, injury, or condition at issue.”

Under this language, treatments that are FDA-approved and generally accepted in the medical profession as safe and effective should not be denied as investigational or experimental.
  Hepatitis C: Because of its exorbitant price ($94,000 for treatment), many insurers decided to deny Sovaldi and Harvoni medication to patients to all but those in later stages of the disease. Lawsuits have been filed against insurers like Anthemand Blue Cross alleging the insurers breached their contractual duty to provide coverage for medically necessary treatment. They further allege breach of good faith and negligent infliction of emotional distress. Anthem Blue Cross Lawsuits filed in California also allege insurers deny treatment to increase profits, a violation of California law.

Attorneys believe that insurers have limited coverage for drugs like Harvoni based upon their profit concerns, regardless whether treatments have FDA approval and medical opinion regarding beneficial use, sometimes for millions of patients. Denials such as these are considered bad faith insurance.

Lipedema: A Blue Cross of California (Anthem Blue Cross) bad faith lawsuit was filed by Attorney Robert Gianelli in the Superior Court of Los Angeles on September 14th, 2018, alleging it wrongfully denied benefits to a woman with stage 3 lipedema. The insurer based its denial on the treatments being cosmetic, but Gianelli argues that Anthem Blue Cross determined there was no in-network provider with the expertise to properly treat the plaintiff. Plaintiff’s in-network doctor informed Anthem that she should see an out-of-network doctor to have the procedure done. Both doctors agreed on the diagnosis of stage 3 lipedema (where fat tissue accumulations beneath the skin protrude and can hinder mobility.) In the early stages, lipedema surgery is often done for cosmetic purposes, but the lawsuit claims this case meets the standard behind California’s reconstructive surgery law.

Artificial Disc Surgery: Anthem Blue Cross, Aetna and United HealthCare Insurance Company have refused to cover lumbar artificial disc surgery despite the fact that the surgery has been FDA approved since 2004 and is frequently performed by renowned surgeons at leading medical centers.

A class action lawsuit was filed against Blue Shield of California over its refusal to cover lumbar artificial disc surgery on the basis it was investigational. (Escalante v. California Physicians Service dba Blue Shield of California) . Blue Shield retracted its “investigational” denial basis and agreed to cover the surgery. The same law firm also won class certification in a case against UnitedHealth Care based upon its refusal to cover artificial disc surgery as “investigational.” (Hill v. UnitedHealthcare Insurance Company, United States District Court for the Central District of California, Case No. SA CV 15-0526-DOC.)

Proton Beam Therapy for Prostate Cancer: Both United HealthCare Insurance Company and Blue Shield deny medical claims for proton beam therapy for the treatment of prostate cancer on the basis it is investigational. Proton beam therapy to treat prostate cancer is an established form of treatment that is widely accepted by physicians, government agencies and many insurers, including Medicare and Medicaid (which do not cover investigational or experimental treatments), and performed at leading medical centers.
  If your treatment has been denied on the basis that it is “investigational” or “experimental”, ” “not medically necessary”, “no medical literature to show it is effective”, and other, similar reasons, it is crucial that you take action ASAP.

Often the insurance company has made the wrong decision. You always have the option to appeal the health insurer’s decision. As well, a denial can prolong needed treatment or surgery that can be life altering or even cause death.

For instance, Terry LaRue, a sports videographer, fell and fractured his hand. He was referred to an orthopedic surgeon to perform surgery the day after his injury but the surgeon would not accept his Health Net coverage. Over the next several weeks, LaRue, age 28, visited other orthopedic surgeons in the plan who each confirmed the immediate need for surgery, but could not provide the necessary treatment as they were not hand surgeons or contracted with the hospitals. After several weeks he finally had surgery, but due to the delay, LaRue suffered permanent impairment and could no longer work at his profession.

With legal help, LaRue filed a lawsuit against Accountable Health Care for failure to provide timely and necessary medical services. LaRue’s health plan, Health Net, contracted with Accountable to create a network of doctors under his Affordable Care Act plan. Accountable also agreed with Health Net to authorize referrals to specialists for Health Net members when they needed it. A jury awarded LaRue $7,225,000 based on Accountable’s negligence and violation of a law relating to managed care entities.

You have the right to appeal twice. After a second appeal and denial there can also be a peer –to- peer review and final denial. The claim denial letter from your insurer has a deadline for submitting an appeal. After filing, the insurer usually has 60 days to make a decision. If you’re denied, you can appeal one more time. At this point, and if you haven’t done so already, you may want to seek legal help.
 

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Last updated on May-20-20