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Did Anthem Deny Your Claim for Treatment in the ER?

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Coverage for an emergency room visit is a basic and crucial feature of any health insurance policy, and for good reason. The costs of being treated in the ER, while necessary and sometimes life-saving, can be astonishingly high and unaffordable without insurance coverage. Unfortunately, not all insurance companies are meeting their obligation to cover emergency care as required. Blue Cross of California, aka Anthem Blue Cross, was recently cited twice by the Department of Managed Health Care (DMHC) for deficiencies in the way it covers ER services for its subscribers.

When policyholders in good standing have a claim for ER treatment denied by their health insurance provider, they may be entitled to money damages for the harm caused by the insurer’s bad faith insurance practices. Contact the aggressive and professional California insurance coverage lawyers at Gianelli & Morris as soon as possible after a denial of coverage for ER treatment, and we’ll put our years of experience to work and fight to make things right.

Emergency room treatment is never a patient’s first choice

Visiting an emergency room can be a stressful and traumatic experience. It’s hard to imagine who would choose to take themselves to the ER and spend time in a chaotic waiting room or be frantically rushed into a hospital by emergency personnel if they felt like they had another option to address a health emergency. In some cases, a patient may be experiencing a set of symptoms that could indicate a life-threatening illness or could indicate a less severe condition. Out of caution when considering that their life could be in jeopardy, a patient using their best judgment in this situation would likely choose to go to the emergency room.

Patients who have a valid health insurance policy are likely to assume that, if they decided in good faith to go to the ER when they were experiencing severe symptoms, their insurer would pay for the visit even if testing revealed that the condition was not potentially fatal. Policyholders are increasingly coming to discover that insurers—especially Anthem Blue Cross—are denying these claims. Immediately after receiving a denial for ER visit claims, call the Los Angeles offices of Gianelli & Morris to find out if you’re entitled to coverage or potential money damages through an insurance bad faith lawsuit.

DMHC says Anthem imposed an improper standard when denying ER claims

In its routine survey and monitoring of Anthem’s health plan, the DMHC identified fourteen separate deficiencies regarding Anthem’s health care delivery system, and two of those deficiencies dealt specifically with the issue of emergency services and payment.

The first deficiency was for improperly denying emergency services and care based on medical necessity by applying an incorrect standard and allowing non-clinicians to make that determination. Anthem told California patients that their claims for coverage of emergency room treatment can be denied if a so-called “prudent layperson” would not have reasonably believed that an emergency medical condition existed. But in an emergency, even a physician might not be able to tell when symptoms indicate a serious condition or when they are those of a less-serious ailment. The Journal of the American Medical Association published research showing that six of the ten most common symptoms described by those making use of the emergency room with non-urgent conditions were also among the top-ten symptoms of persons visiting the ER with actual emergencies. Patients may be imperiling their health by making the judgment call not to go to the ER when their symptoms may or may not be serious.

Despite having years to make changes to correct this deficiency, the DMHC has determined that Anthem still has not corrected this deficiency. Anthem was also cited for failing to give policyholders a clear and concise explanation regarding Anthem’s decisions to deny ER claims. This deficiency, too, was found by DMHC not to have been corrected.

Call Gianelli & Morris if You Believe Anthem Improperly Denied You Access to Emergency Services and Payment

When denying a claim for ER treatment only after diagnosis, Anthem and other insurers have the advantage of hindsight that patients don’t have when deciding whether to visit the ER. Patients experiencing extreme pain and symptoms that could indicate a life-threatening condition should not have to doubt their insurer will cover a visit to the ER that could save their life.

If you or someone you love has had a claim for coverage of a visit to the emergency room denied by your California health insurance provider, contact the dedicated and knowledgeable Los Angeles insurance bad faith lawyers Gianelli & Morris for a no-cost evaluation of your claim at 213-489-1600.

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