Health Insurance provider refusing to pay claim

[teck5a]

What is the name of your state? Florida

Hello,

My wife required surgery, last year, for a potentially life threatning illness. Our Health plan did not have a Surgeon available, in the network and our in network doctor brought a Surgeon in to the case.

The Insurance company has refused to pay this claim because it was not authorized before the surgery. Our PCP and the Specialist have both written letters stating that they could not find an in network surgeon and the surgery could not wait until the Insurance company got their act together, so they went forward as they saw fit.

This company's own "Customers Rights and Responsibilities" claims that we "Have the right to be provided access to Health Care, Physicians and Providers". My contention is that we did not seek this out of network provider and they failed to provide one, therefore they are responsible for payment.

I know it's probably difficult to say without all of the details of the Case, but, based on the info provided, do I have grounds to sue them under Breach of Contract or possibly Fraud, after I have exhausted all of my Appeals? I mention Fraud because I am supposed to be able to use out of network physicians and they are supposed to pay 70%, but they are backing out on that, as well.

Thank you,
Teck5a

 

[cbg]

In many plans, it is necessary to have approval beforehand before using an out of network provider. Is this the case with yours? If so, you can ask them to make an exception based on the life-threatening situation, but you have no basis to sue them. If that is indeed the case, they did not breach the contract; you (or perhaps I should say your doctors) are the ones who acted outside of the contract guidelines. (Please note that I am not saying you did wrong; I understand that your wife was in a life-threatening situation; I am saying only that IF the plan requires authorization before using out of network providers, then under the contract they are not required to pay for the services of out of network providers for which there is no authorization and to refuse to do so would not be a breach of contract.)

 

[lkc15507]

Lots of info in this post. I'm simply going to make some observations. A denial based on a lack of pre-authorization would need to be pretty specifically stated in your plan document--whether in or out of network. Most plans I am familiar with request preauthorization for certain services and network determinations--yet the ultimate determining factor is based on medical necessity. Not that what you have described isn't possible, it is, yet I would want to investigate. (I am more familiar with plans imposing benefit penalties rather than out-right denial of claims.)

There are also ERISA regulations that determine how long an insurer has to make a determination on a pre-service claim. At this point, I think your words "potential life-threatening" become very important. Was there time for the provider to submit an "urgent" predetermination request and did they do so? "Potential life-threatening" would not necessarily mean urgent or emergent. Letters from the providers after the fact may not be enough to fulfill the predetermination requirement. It will likely depend on your wife's diagnosis and clinical status. For example: cancer is life-threatening, yet surgery may not be immediatley required or emergent--hemorrhage from a lacerated artery is likely an emergent situation that does not lend itself to a predetermination. Health plans cannot impede appropriate health care delivery. It would need to be determined if the necessary time to make a predetermination impeded appropriate, emergent health care delivery.

Lastly, usless specifically stated otherwise, an insurer can determine medical necessity post-service, even if they request pre-service determination. Read that plan document. Your plan document will also describe your appeals process. Under ERISA (if you belong to an ERISA plan, most are), to have a complaint, it is very important to follow that process to the letter. Your appeals correspondence should have specifically stated that it is an appeal. Otherwise it might be considered a simple inquiry (this could certainly be in your favor). If your written correspondence has not specifically stated that you are making an appeal, read your plan document and do so now. Hopefully you are still within the time frame allowed to appeal.

lkc15507