Can a doctor at an insurance company make a decision to deny care if he or she doesn’t even look at the patient’s medical records?
This is a question that the California insurance commissioner Dave Jones will be looking at during a new investigation of Aetna following this stunning admission. Jones told CNN his expectation would be “that physicians would be reviewing treatment authorization requests.” I think we all would agree.
This is concerning to us as consumer attorneys in Florida who note that Aetna is a long term care insurance company who reviews people’s applications for nursing home and Assisted Living care.
The admission arose from a case going to trial this week in California brought by Gillen Washington who sued Aetna for breach of contract and bad faith. While Mr. Washington is only 23 and this was a different type of insurance, the question arises about how widespread this “non-review” of medical records is?
This testimony shows a need for “more transparency and accountability” from private, for-profit insurers in making these decisions stated Dr. Arthur Caplan, founding director of the division of medical ethics at NYU Langone Medical Center.
If you’ve been denied or delayed long term care insurance coverage, please reach out to us or someone in your area to determine if the denial of coverage is legit or if some kind of legal action is warranted. Most attorneys offer a free consultation and many work on contingency fee where they don’t get paid unless there is a recovery.
Similar to Mr. Washington’s case, there are avenues to force the insurance company to pay up including breach of contract and bad faith. Since most long term care insurance companies are losing money on older policies they have a motivation to deny coverage whenever possible.
The good news is that long term care coverage is often denied due to ambiguous terms in contracts drafted in the 80s and 90s and ambiguities are decided in favor of the consumer whenever litigation occurs. But you have to litigate or threaten to litigate to get that far.
Having an attorney in your corner to make sure the insurance company abides by the insurance contract can be a good idea especially in contentious cases. Or in cases where the caregiver simply does not have the time to read up on all of this to know when the wool is being pulled over their eyes and coverage ends up being denied.
For more information please see our website and call us for a free consultation.