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In recent years, we have observed a growing trend of insurance carriers making bolder and bolder denials of coverage for medical expenses in cases involving third party caused injuries. These denials are often accompanied by an “explanation” that the carriers bear a “responsibility” not to pay for treatment that is considered unreasonable or not causally connected to the injury producing event. Such a denial of benefits usually prompts us to contest the carrier’s finding, seeking a reversal and eventual payment of the bills. We have found that even with the involvement of an attorney, and a clear showing of the relationship of the billing to the injury event, carriers continue to hold to the denial mindset, and reversal of their original position seldom occurs unless great pressure is applied. Notably the carriers are refusing coverage in situations where the have a right of reimbursement. So, they are denying payment of benefits that they often receive back through the insured’s lawsuit or claim.

Another disturbing trend that we are seeing, is the “denial” mentality that is now exuding in the health care insurance industry. Coverage denials in these cases often occur while patients are desperately seeking “authorization” or “approval” of procedures recommended by their physicians. In denying or delaying such authorization, the patient is often put at great risk, and may even die before the treatment is obtained. We remember the heart-wrenching story of 17 year-old Natline Sarkysian whose liver transplant was denied by Cigna, which then reversed its denial under the heat of national publicity, only to have the young girl die days later. See our prior post.

A recent survey performed by the Toledo Blade revealed that physicians viewed the routine challenges of their medical orders by health insurers to be an “emerging crisis.” The survey involved 920 members of the Ohio State Medical Association and American Medical Association. Of this number, a startling 99% reported that insurers had interfered with their clinicial decisions and recommendations. The doctors were critical of the lapse in time often caused by insurer review and interference. Fourteen percent of the respondents reported that patients were seriously injured or harmed by the insurer’s interference in their clinical judgment or recommendations. While it is recognized that this was not a scientific study, the near unanimity of the experiences of these physicians is alarming and should prompt action.

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