California Residents Fight Health Plans’ Denial of Medical Care
Each year, thousands of Californians are unable to receive treatments prescribed by their physicians because their health insurers refuse to cover the cost of the care, the San Francisco Chronicle reports.
The majority of treatment disputes are over whether the patient's therapy is medically necessary or considered to be experimental or investigational.
Patients have a number of resources to turn to if they believe their insurer has unfairly denied them necessary care, according to the Chronicle.
Meanwhile, the state's HMO Help Center received nearly 90,000 calls from consumers seeking assistance with health plan issues.
About 7,000 Californians also have used the Department of Managed Health Care's third-party medical review system since 2001. Last year, 1,716 medical review cases were resolved by the department.
DMHC said about 40% of all independent medical review cases are settled in favor of the patient.
The Department of Insurance, which regulates a smaller number of health plans than DMHC, received 35,280 complaints in 2007 and resolved 262 of them.
If state appeals are unsuccessful, patients can sue their health plans. However, it can be difficult to obtain a lawyer for such a case, and most health plans require their members to agree to binding arbitration, the Chronicle reports.
The Chronicle includes three case studies of Northern California patients' disputes with health insurers over denial of care (Colliver, San Francisco Chronicle, 6/23).