If your health insurer denies coverage for a particular
procedure or course of treatment, it’s critically important to talk to an
attorney. That’s because in many states there’s an official external review
process in which the decision might be overturned. If a wrongful delay in treatment ends up
causing you medical problems, you may be able to obtain damages in court as a
result of the insurer’s failure to honor its contract with you.
Take a recent case out of Minnesota.
In that case, a man was diagnosed with bone cancer in March
2014. After two surgeries, his physicians recommended that he receive
proton-beam radiation therapy. But his insurance policy with Blue Cross Blue
Shield Minnesota considered the procedure investigative when treating the
thoracic spine, where the tumor was located, and under its contract BCSBM
wouldn’t pay for services that weren’t medically necessary or that were related
to “investigative care.”
A radiation oncologist sent a letter to BCBSM describing the
procedure as medically necessary, but the insurer still denied it.
The patient appealed the decision, but by this time nine
months had already gone by and the tumor was wrapped around his spinal cord.
Again, the insurer denied coverage.
The patient then requested external review pursuant to state
law, and just over a year after the initial diagnosis the reviewing panel
overturned the denial of coverage. BCBSM paid for the therapy.
The patient then took BCBSM to court, alleging that the
denials were a breach of his insurance contract. A lower court dismissed the
case, finding that there was no breach because BCBSM ultimately paid. But the
state court of appeals overturned the decision, deciding that because the
external reviewer found that the procedure was, in fact, a medical necessity
under the contract, the patient could bring a case accusing the insurer of