Health Insurance Treatment Or Claims Denied For “Medical Necessity”
Before approving a service or paying a claim, health insurers normally require a showing of medical necessity. Insurers like Anthem Blue Cross and Blue Shield of California require necessity be shown before providing coverage or pre-authorization for many procedures, treatments and medical supplies. For example, Anthem Blue Cross may require patients to establish that back surgeries, organ transplants, prosthetic devices or certain mental health treatments are medically necessary before approving them. Health insurers often wrongly deny services as not medically necessary where the patients’ treating physicians have recommended the services as the most appropriate form of treatment. Health insurance companies do this to save money.
Fighting a Medical Necessity Denial based on medical necessity is generally affected by whether the insured (the person who has the insurance) has an Employee Retirement Income Security Act (“ERISA”) or non-ERISA health insurance policy. Non-ERISA insureds generally work for a government entity (teacher, police officer, firefighter, etc.), a church or purchased their insurance on their own or through Covered California. Most other insureds fall under ERISA.
Los Angeles Insurance Lawyer for Claims Denied
The Law Offices of Scott Glovsky is leading the charge in California against Anthem Blue Cross, Blue Shield of California and other insurance plans that are denying coverage to members on the basis that the services are not “medically necessary.”
“A medical necessity denial is one that insurance companies often use simply to minimize costs even though it comes at the expense of the health and interests of their members,” says Los Angeles health insurance lawyer Scott Glovsky.
The Law Offices of Scott Glovsky will help you seek justice. Click here for a free consultation.
Medical Necessity Coverage Denials Are Often Wrong
In a recent health insurance investigation, regulators reviewed a batch of coverage denials from Kaiser Permanente and found that in cases where Kaiser denied coverage, the overwhelming majority of the services sought were in fact medically necessary.
Health insurance denial lawyer Scott Glovsky says, “The intricacies of the law and how it relates to the standards and criteria that health insurance companies use to evaluate service and benefit requests are very complicated. The best action to take when an insurer denies coverage for a service that is critical to your health, your child’s health or a family member’s health is to call a health insurance denial lawyer. Although you can appeal a denial on your own, it’s worth a call to an attorney to see if they can help.
Los Angeles Health Insurance Denial Attorney Fights for Justice
The Law Offices of Scott Glovsky focuses on health insurance denials for insureds who fall into the following key categories. We help:
- Public employees – you’re a teacher, firefighter, police officer, city worker, county worker, or other public employee
- Seniors – you’re on Medicare or in a Medicare Advantage plan
- People who purchased insurance directly from health insurance companies
- Covered California Buyers – you purchased your plan through Covered California
- Religious Organization Employees – you work for a parish, church, diocese, synagogue, or a similar religious organization
- EPO Plan Holders – you have an exclusive provider organization (“EPO”) plan
If you fall into one of the above categories, call our office at (626) 243-5598 .If you are not in one of the above categories, you are likely subject to ERISA. If you are subject to ERISA, you need to see a lawyer specializing in ERISA cases.