Los Angeles, CAA couple of California residents experienced very different outcomes with regard to insurance claims for medical procedures. Both claimants had their insurance claim denied, although one policyholder successfully had her denial overturned with the help of the State of California.
California insurance law, similar to federal law and statutes in other states, governs the conduct of insurance companies with regard to provision for funding procedures and services that fall within the covered items in the policy. While there is some discretion in many instances, the trend for many insurance companies is to deny legitimate claims as a matter of policy, and pay only when forced to do so under the threat of litigation by an insurance lawyer.
Kalana Penner is a 33-year-old mother and student who suffers from a nerve condition that causes chronic pain. After several treatments and procedures had been attempted without success, Penner's neurosurgeon recommended an implant. Penner's insurer, Health Net Inc., allegedly denied her California insurance claim.
Penner did not accept Health Net's position at face value, and appealed their allegedly bad faith insurance position through an independent medical review. As reported by the Los Angeles Times (9/13/12), the California State appeals process overturned Health Net's denial, and Penner was afforded the opportunity to have the surgery.
There are countless claims of California health insurance fraud after claimants, having faithfully paid premiums for years, find their claims are summarily denied. According to the LA Times, the California Department of Managed Health Care received no fewer than 1,213 requests for an independent review in 2011. In the minority of cases??"39 percent??"the position of the insurance company was upheld. The remainder were overturned by an independent review, or voluntarily reversed by the insurer before a ruling was ever issued.
Robert Mendoza was 59 when he was diagnosed with a rare, but aggressive form of prostate cancer. His doctor recommended a procedure that would be robotic-assisted and minimally invasive. Mendoza??"as is the case with many patients??"sought a second opinion from the USC Norris Cancer Hospital, which recommended extensive surgery due to the advanced nature of his condition.
While Health Net approved the initial, less-expensive treatment, it was unwilling to cover the surgery recommended by the hospital and Mendoza had his insurance claim denied.
He had the surgery anyway, paying $30,000 out of his own pocket, feeling the surgery gave him the best chance for survival.
In September, both Mendoza and Penner sought California insurance claim help by launching a bad faith insurance lawsuit against Health Net. Inc. It has been reported that the Los Angeles County Medical Association joined the two plaintiffs in their lawsuit.
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