Q&A: Can you sue a health insurance company for denying medical coverage?
August 12, 2012 by Foot Health
Filed under Foot Health FAQ
Question by CMS: Can you sue a health insurance company for denying medical coverage?
My doctor has referred me to have the gastric by-pass surgery. I’ve spent the last 4 months and countless money (of my own) getting all the things the done the insurance company has asked for. This includes psych evaluation, sleep study, nutrition counseling, physicals and documentation to include I have tried at least 2 non-surgical weight loss programs for over a year with no long term success. Finally after submitting everything, they denied me for “no recent active participation in a non-surgical weight reduction program”. My last weight loss attempt was a year ago. I am about to lose my job because I cannot literally stand up on my feet anymore. This is something I have to get, not something I just want. It would seem if both my primary physician and the specialist both agree this is medically necessary, then the insurance companies couldn’t deny someone their health.
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Answer by spot
They can and they have done it to other people. The treatment you are talking about is not 100% safe. Some people develop complication from it. Maybe that is why they reserve it as the last resort. It shouldn’t be hard to participate in a non-surgical weight reduction program. After that, they may pay for the surgery. Good luck.
Know better? Leave your own answer in the comments!
Insurance companies are not required to cover this sort of procedure. You should familiarize yourself with your policy to see if they are lying to you but chances are that they are in the right.
If you really feel that they are misleading you then you may want to see an attorney to help you review your policy and try to find a way to force the insurance to pay for the procedure.
In conclusion, just because something is believed to be medically necessary does not immediately force an insurance company to pay for it.
You could sue, but it’s easier to file a complaint with your state’s insurance commissioner’s office. It’s free and they have access to contracted physicians who review the medical necessity of the procedure. In this case, it appears the specialist would also review the carrier’s medical necessity guidelines to see if they’re too stringent. Given the radical nature of this surgery, it doesn’t sound outrageous to me that you’d be required to have participated in a recent weight loss program that’s medically monitored and guided.
I hope this helps.
You can sue anyone for anything, so the answer is yes. The cost of the lawyer might be A LOT, you’ll have to pay that up front.
If the contract (policy) specifies that they won’t cover gastric by-pass – and a lot of them don’t – then, well, they don’t cover it! So you’ll lose your suit.
You really need to sit down and read the policy.
AND you need to appeal their decision. Meanwhile, while you’re waiting for the appeal, join up with TOPS or WW, go to the weekly meetings – because that IS active participation. The appeal will take weeks.
Covering the gastric bypass and similar procedures is relatively new for insurances who have always lumped this with being cosmetic.
Most insurances are now starting to cover these procedures but they have criteria you must fall under and hoops you must jump through in order for you to be approved. Such as, being over a certain BMI for one. They expect that you have severe documented instances of knee/ankle/leg pain from walking and back pain that you have been treated for thus far.
Some do have criteria for having “failed” at some form of dieting/weight loss program and most require you to have been on this plan at least 3 to 6 months prior to having made your appeal.
Can you sue them for not approving you, you can try. The thing is that they will probably win. You can file a complaint with the Department of Insurance in your area, you can also complain to the Agency for Health Care Administration.
You can also try and have the decision overturned within the insurance. If you’re adamant about suing call an attorney nearby and see if he thinks you have a case.