Aetna, one of the largest insurance companies in the United States, has been in the news lately. A former medical director from the insurance company admitted under oath that he never actually looked at medical records or researched the condition an insured patient was seeking treatment for. Still, Aetna denied the patient’s insurance claims, saying that the procedures were not medically necessary. Ultimately, this case went to court, with the patient suing for bad faith insurance denial. The Philadelphia Aetna negligent insurance denial attorneys at The Reiff Law Firm explain how this may open Aetna to more lawsuits, and how you may be able to sue an insurance company for denied benefits.
Suing for Denied “Medically Necessary” Treatment
Under many insurance policies, claims are submitted to the insurance company by your healthcare provider. Some healthcare providers may request pre-approval for treatment, especially if it will be very expensive, rather than risk having payment denied after treatment. If the insurance company denies coverage or pre-approval for the treatment, it may be impossible for patients to afford the treatment. Doctors are never happy to see their patients’ claims denied, especially if they are advocating for medically necessary treatments and procedures.
Under our insurance system in the US, the insurance company – not your doctor – ultimately decides whether something is “medically necessary” and will be covered. The threshold of “medically necessary” is usually the threshold for when an insurance company must cover your claims, under most insurance policies. Other optional procedures may be good for you, but your insurance might not cover them. If they see the procedure as optional rather than life-saving, they can deny your benefits.
The problem with the recent Aetna case is that the insurance company made decisions with little to no medical basis. The medical director, who spoke under oath in this case, was a physician in charge of approving or denying treatments as medically necessary. When confronted with the question of whether treatment for a rare condition would be approved or not, the director denied the claim and the procedure’s necessity. In doing so, the director admitted he never looked at the patient’s medical records, did not research the condition, and did not know what drugs were effective in treating it. Yet he said that the requested treatment was not medically necessary.
The patient in this California case sued for breach of contract and bad faith insurance denial, claiming that the denial of benefits was unjustified. Although nurses that work at Aetna apparently reviewed his medical records, it is unclear what information, if any, the director had when he denied the claim. If the claim was denied without any real investigation, research, or medical opinion, the claim may have been denied in bad faith.
Damages for a Lawsuit Against Insurance Companies like Aetna
If you are unable to get pre-approval for medical treatment, you may be unable to receive treatment entirely, or you may be forced to pay out-of-pocket for the procedures. If you are unable to afford the treatment, your condition may grow worse. In some cases, this can lead to extreme pain and suffering, increased medical costs down the line, and may force you to miss work or lose your job. In other cases, denied health insurance claims may lead to death. If this is the case, you may be entitled to compensation for all of these financial loses, as well as pain and suffering. For the death of a loved one, you may be entitled to compensation for their loss, their suffering, burial costs, and other expenses.
If you are already receiving treatment, stopping treatment may be catastrophic. If you switch insurance companies during your treatment or your insurance company refuses to continue coverage for your ongoing care, the effects could be terrible on your system. The pain and suffering from suddenly stopping some medical treatments may take a terrible toll on your health, leaving you further incapacitated or vulnerable to complications and side effects. If the insurance company’s decision to cancel your benefits was unjustified, you could be entitled to substantial compensation.
Proving these damages may require proving certain factors in court. In the Aetna case, the company has defended their medical director by saying that he followed the company’s proper protocols in making the decision to deny coverage. However, just because the worker followed protocol does not mean the protocols are justified. If the insurance company’s review of your claim was handled in bad faith or had less care and attention than is reasonable, you may be entitled to compensation for the denied benefits.
Philadelphia Aetna Denial of Benefits Lawyers
If you or a loved one was denied medical care because an insurance company negligently denied your claim or denied your claim in bad faith, talk to an auto accident attorney. You may be entitled to substantial compensation for the additional medical costs, lost wages, and pain and suffering from untreated conditions or suddenly stopped treatment. If you lost a loved one, the damages may be even more substantial. For a free consultation on your case, contact the Philadelphia personal injury lawyers at The Reiff Law Firm today at (215) 709-6940 today.
