On what grounds can Insurers deny ADR?

[Texas-T]

My fiancee, Jeff, is working on a paper for Grad school about insurance companies denying procedures approved by the FDA (like ADR) and could use a few leads. Any help would be greatly appreciated.

Does anyone know what gives insurance companies the right to deny ADR a FDA approved procedure? (i.e. is there a law that allows them the to pick and choose what they'll cover?)
Does ERISA allow insurance companies the power to deny FDA approved procedures?

I was very lucky and Aetna approved my ADR after little fan fair. (I was previously denied by UNHC) Does anyone know why some companies will pay for the surgery, while other's won't?

We understand the appeals process, but do you have the right to sue your insurance company if they deny you after following through with the appeals process? Our understanding thus far is that if you are not a federal employee you must sue in Federal Court where you are at a disadvantage and are not elligable for $$$ for pain and suffering. (b/c of ERISA) If you are a Federal Employee you can sue in State Court. Does anyone know if this is correct?

I know this may be a little complex... so any leads would be helpful.

Thanks again for the help.

Tricia

[LBP]

Tricia,

I think the terminology you're looking for is "bad faith insurance" lawsuit. If I had access to westlaw I would do some online research. Does your fiance know any law students? They have free access to westlaw. I've been meaning to go to the law library to check into this. I think there is a possible class action lawsuit here.


for example, in a quick google search here's a website that lists a number of examples that may consitute "bad faith"
http://www.hugesettlements.com/articles/Insurance_Law.htm

[Eddie_G]

The doctors they pay are fossils and they like it like that

Out of state claims

General greed

General stupidness

General uncaring

They think you're nuts

They're evil

Their parents hated them and now they're taking it out on us

Oh they have grounds all right!

[Nairek]

LBP,
If my Wills, Trusts, & Estates professor gets on the ball sometime soon, I'll have access to Westlaw. I myself am interested in doing some reasearch on this.

[Nairek]

Tricia,
I was denied by Empire BC/BS when I asked them to pay for a 1-level Charite ADR. Their reasoning both times (pre-certification & 1st level appeal), was that it is experimental/investigational.

In their contract with my employer, it states that they can deny coverage for any procedure that they deem is experimental/investigational. In my research for my appeal, I found that some BC/BS plans will pay for this procedure whereas others will not. The decision lies with each individual plan & some plans that will cover this procedure can turn around & reverse their decision & decide that they will no longer cover it.

As for suing your insurance company if they deny coverage after all appeals are exhausted, I'm not sure. I've been told by my OS that a class action lawsuit could be brought against an insurance company. However, who can afford to foot that bill?

You may want to check out your local department of insurance as a starting point for your research. Here's the link: http://www.idfpr.com/DOI/Default2.asp
Hopefully this helps you out! http://adrsupport.org/groupee_common/emoticons/icon_smile.gif

You absolutely have the right to sue the insurance company - but only in Federal Court and only after you have exhausted the appeals process and external review, if required - unless you are a special category employee as you described.

Yes .. ERISA places you at a disadvantage in Federal Court ... but if you are diligent in the appeals process and the insurance company fails to respond in a timely manner, you will then have a separate cause of action (breach of contract, failure to disclose under ERISA). You may thus be able to get a cause of action in state court. The specifics of this will vary dependning upon which state you live in and the State Insurance Dept. Regulations. It is always important to request the medical qualifications of reviewers who are involved in the appeals process. It would also help to have your surgeon document the cost of ADR vs alternate procedure (fusion). It will also help if your insurance company has a history of non-compliance or has been fined by the State Attorney General's Office, or has a class action suit against it for deceptive marketing practices. You should request a copy of the contract your employer has with the insurance provider. They are required to provide this, regardless of what they say concerning confidentiality, and I can provide the relevant statutes if requested.
Are there any discrepancies between the materials you were provided when you commenced employment and the current policy? Were you given notice of changes?

Pain and suffering- unfortunately the legal view will be that you could have always financed the operation yourself. This is why you need to look at other causes of action. Does your insurance company have a policy specifically for ADR? If so, is the information in it accurate or does it state any gross factually incorrect information?


My understanding from attorneys is that $70,000 in unreimbursed medical expenses is about the breakeven point at which an attorney will consider it economical to take over a case like this. As most ADR comes in under this, you will probably have to do the legwork and research yourself.