Anthem “Lack of Medical Necessity” Insurance Denial Despite Debilitating Disease Switch to ADA Accessible Theme
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Gianelli & Morris Helps Client Overcome “Lack of Medical Necessity” Insurance Denial

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Recently on this blog, we discussed one of the principal reasons given by health insurance providers in denying claims: lack of medical necessity. Insurance providers sometimes reject a claim as medically unnecessary even when the treating physician recommends the treatment to deal with a given illness or injury. Insurers try to shield themselves by hiding behind the findings of a medical group that go against the suggestion of the actual treating doctor, but that medical group has a financial incentive to back the insurer based on its contractual relationship with the carrier.

Read on to learn about a recent example of a health insurance provider rejecting a policyholder’s request for treatment on spurious grounds of lack of medical necessity. If you’ve had a health insurance claim wrongfully denied on medical necessity or other grounds, call the dedicated and passionate Los Angeles bad faith insurance denial attorneys for assistance getting the treatment you need and the coverage you deserve.

Anthem Rejects Proposed Treatment as “Cosmetic” Despite Recommendation of Doctor

A client of ours who was insured through Blue Cross of California (dba Anthem Blue Cross) was suffering from a painful and debilitating disease. She dutifully went to an in-network doctor for consultation and treatment. The in-network doctor stated that he lacked the requisite experience to treat a condition of her severity, and recommended to Anthem that she be treated by an out-of-network specialist. Indeed, there was no in-network doctor with the requisite expertise to treat our client’s serious condition. Both doctors agreed with the diagnosis and suggested treatment.

Anthem, after many delays, categorically rejected our client’s request for the treatment specifically prescribed by a specialist in the area of her condition. Anthem claimed that the treatment was not medically necessary and therefore excluded by the policy. Anthem made this claim despite acknowledging her diagnosis and understanding the treatment can be used to improve health. The company knew full well that the proposed treatment was meant to treat a debilitating disease and that delaying her treatment would exacerbate her condition and cause her additional pain, suffering, and potential disability.

Wrongful Denial of Procedure Violates Contract and Law

Our client’s case is far from unique. Anthem and many other health insurance providers will often look for any reason to deny health insurance claims. Despite scientific consensus in favor of specific treatments for certain conditions, health insurance companies rely on blanket exclusions that ignore medical facts on the ground.

When a health insurance provider wrongfully rejects a claim, they are violating more than the language of their own policies; they are violating California law and potentially acting in bad faith as well.

Thankfully, we were able to obtain a favorable result for our client. Her experience, however, is all too common. If you’ve been the victim of a wrongful claim denial or bad faith by a California health insurance carrier, get help you can trust from the professional and effective Los Angeles insurance bad faith lawyers at Gianelli & Morris by contacting them for a free consultation at 213-489-1600.

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