If you or a loved one have a respiratory condition, you are fully aware of how traumatic it can be to be unable to breathe. If your doctor has prescribed a treatment, procedure, or prescription drug that has subsequently been denied by your insurer, it can be even more devastating. Many insurance companies are often primarily interested in the financial bottom line. They want to make lots of money for their shareholders, CEOs, and other high-up individuals. Unfortunately, policyholders who purchase insurance are often at the bottom of the list as far as who the insurance company wants to keep happy.
Many people who receive an insurance denial simply accept the denial because they do not believe anyone can go up against a big corporation and win. In many cases, this is likely true, but when you have a strong legal advocate like attorney Scott Glovsky, who never hesitates for a moment to go up against a large corporation, your chances of a positive outcome increase exponentially.
What Are the Most Common Respiratory Conditions?
While there are many different respiratory conditions, the most common ones include:
- Lung cancer can be difficult to detect, developing in the main part of the lungs, near the air sacs. Mutations then cause irregular cells to grow and create a tumor. Like many other respiratory conditions, lung cancer is often caused by cigarette smoke but can be caused by radiation exposure and air pollution.
- COPD, or Chronic Obstructive Pulmonary Disease, encompasses several different respiratory illnesses that cause breathlessness and the inability to exhale. It can develop over the course of several years, often going undetected until a person reaches his or her 50s, 60s, or 70s. COPD is the fourth leading cause of death in the world according to the World Health Organization and is usually associated with cigarette smoking. It can result in difficulty performing normal daily activities.
- Pneumonia results from an infection in the air sacs of the lungs and can be fungal, viral, or bacterial. Pneumonia can be life-threatening, but most people will recover in one to three weeks.
- Chronic bronchitis is a type of COPD that includes a chronic cough. Acute bronchitis develops from a viral or bacterial infection.
- Emphysema is another type of COPD that is usually caused by smoking. Emphysema causes the patient to be unable to exhale air from his or her lungs because the cigarette smoke has damaged the air sacs in the lungs.
- Cystic fibrosis is caused by a defective gene that causes thick mucus to clog up breathing passageways, often leading to serious lung infections.
- Asthma is the most common respiratory condition, with more than 28 million people across the United States diagnosed with the condition. Asthma inflames the airways, causing shortness of breath, tightness in the chest, wheezing, and a dry cough. Environmental allergies can exacerbate asthma. Asthma usually begins in childhood, although some people can develop adult-onset asthma.
- Walking pneumonia is a milder form of pneumonia caused by bacteria. It is usually less severe than “regular” pneumonia and is called walking pneumonia because those who contract the disease are often unaware they have it and keep going about their normal routines. Walking pneumonia is contagious and is spread through respiratory droplets.
- Pleural effusion develops when fluid collects between the chest wall and the lung as a result of cancer, congestive heart failure, or pneumonia. Patients generally notice shortness of breath and an increasing level of chest discomfort.
What Are the Most Common Treatments for Respiratory Conditions?
Treatments for respiratory conditions will depend on the exact condition but may include:
- A nebulizer (compressor, jet, ultrasonic, mesh, or membrane) can be used to help loosen mucus.
- Bronchodilators that are usually inhaled and relax the airway muscles (Ventolin, Proventil, Atrovent, Xopenex, ProAir).
- Inhaled corticosteroids to lessen airway inflammation, or oral steroids, usually to prevent the worsening of COPD.
- Combination inhalers like Duaklir, Pressair, Bevespi, Aerosphere, Stiolto, Ellipta, Anoro, and Respimat lessen airway inflammation.
- Phosphodiesterase-4 inhibitors to lessen airway inflammation (Daliresp, Theophylline, Elixophyllin, Theo-24, Theochron)
- Antibiotics
- Oxygen Therapy
- Pulmonary rehabilitation programs
- Lung volume reduction surgery, endoscopic lung volume reduction, lung transplants, and Bullectomies are more invasive treatments.
- Replacement of the Alpha-1-antitrypsin deficiency protein to prevent further damage to the lungs.
What Are the Reasons a Respiratory Condition Treatment Could Be Denied?
Your respiratory condition treatment could be denied for a simple reason, like insufficient information, using an out-of-network provider, or receiving a treatment that is specifically not covered. Many lesser issues can be fixed, and the claim can be resubmitted. When a treatment is expensive, you are more likely to receive a denial letter from your insurer claiming the treatment is not medically necessary or is experimental or investigational.
What Should You Do if Your Respiratory Condition Treatment Is Denied?
Most importantly, do not give up if you receive a respiratory condition insurance claim denial. You can submit an internal appeal that asks your insurer to reconsider the denial. Including a letter from your doctor that details all the reasons you need the specific treatment can help you receive approval. If your internal appeal is unsuccessful, you can file an external appeal, which puts the matter before a neutral third party. The decision of this third party is binding on your insurance company. We recommend speaking with a highly experienced health insurance denial lawyer before you file an external appeal because, depending upon your unique situation, you may want to file a lawsuit instead of filing an external appeal.
Which Insurers Are More Likely to Deny Treatments?
Although any insurer can issue a respiratory condition insurance claim denial, some companies are more likely to do so than others. These are the insurers in California that may issue a claim denial:
How the Law Offices of Scott Glovsky Can Help with a Respiratory Condition Insurance Claim Denial
The impact of a respiratory condition that leaves you unable to breathe is undeniable and traumatic. If you are facing a respiratory condition insurance claim denial, contact the Law Offices of Scott Glovsky for the help you need. Attorney Scott Glovsky and his legal team will work tirelessly on your behalf to make the insurance company live up to its promises.