Life-Saving Treatment: Fighting For Your Rights When Denied By Insurance

It is a tragic reality that insurance companies sometimes deny life-saving treatments, putting their profits before people's lives. When this happens, patients and their doctors should work together to understand their options and act quickly to get the required treatment approved. There are various options to fight the insurance company's decision, including appealing the denial, filing a lawsuit, or seeking financial aid from non-profit organizations.

Seek legal advice and understand your rights

If your insurance company denies you coverage for life-saving treatment, it is important to understand your rights and seek legal advice. Firstly, you have the right to appeal the decision. This can be done through an internal appeal process with your insurance company, where you request a full and fair review of their decision. If the case is urgent, the insurance company is required to expedite this process. If the internal appeal is denied, you can take your case to an external review by an independent third party. This removes the insurance company's final decision-making power over the claim.

It is also important to work closely with your doctor, as they can provide additional information or peer-reviewed sources to support the request for prior authorization. Your doctor can also participate in a "Peer-to-Peer", where a medical physician from the insurance company discusses the case with your doctor before making a decision.

If your insurance coverage is governed by ERISA, you must comply with its appeal requirements. However, if the situation is critical or life-threatening, the appeal process may not be a viable option. In such cases, you may have to pay for the treatment out-of-pocket and then file a lawsuit for breach of contract and bad-faith insurance claim handling. If you are unable to pay out-of-pocket, you can still file a lawsuit and seek a temporary restraining order or injunction to prevent immediate or irreversible harm.

To fully understand your rights and the best course of legal action, it is advisable to contact a lawyer or seek advice from organizations such as the Patient Advocate Foundation (PAF) or Mended Hearts, which provide support and resources for individuals facing insurance denials for life-saving treatment.

Appeal the decision, providing additional evidence to support your case

If your insurance company denies a claim for life-saving treatment, you have the right to appeal the decision. This is because they are often putting their company's profits ahead of your health and well-being. In fact, in March 2024, Forbes reported that "on average, 6% of prior authorization requests are initially denied. Of those, 11% are appealed, and 82% are ultimately fully or partially reversed." This means that most people don't appeal because they don't realize it's an option.

There are two ways to appeal a health plan decision: an internal appeal and an external review. For an internal appeal, you may ask your insurance company to conduct a full and fair review of its decision, and they must tell you how to dispute their decision. If the case is urgent, they must speed up this process. For an external review, you can take your appeal to an independent third party for review. This means that the insurance company no longer gets the final say over whether to pay a claim.

If your treatment was denied, it's important to work with your doctor, as they can provide additional information to support your prior authorization request. For example, they can provide peer-reviewed sources that cite the effectiveness and positive outcomes associated with the treatment. You will then need to send a letter of appeal to your insurance company. This letter should include the previous prior authorization reference number, your diagnosis, and the CPT codes associated with the requested procedure. Then state why you are requesting this appeal, including how it will impact your quality of life and health, and why your care team feels it's necessary.

If your health coverage is governed by ERISA, you must comply with its appeal requirements. However, if it is a critical or life-threatening situation, the appeal process may not be an immediate or viable option. In this case, you may have to pay for the medical treatment out-of-pocket and then file a lawsuit for breach of contract and possibly for bad-faith insurance.

Request a temporary restraining order or injunction to prevent irreversible harm

If your insurance company denies you life-saving treatment, you can take legal action to obtain a temporary restraining order or injunction to prevent irreversible harm. This is a mechanism for obtaining fast relief, and it is important to act quickly as the appeal process may not be immediate.

To obtain a restraining order or injunction, you must file a petition or complaint in court, along with a request for an emergency hearing. The court will consider who would be hurt more—the person requesting the order or the other party—and will aim to protect the one at greater risk. The court must also preserve any party's right to a jury trial. The jury will hear all the evidence, even if it has already been heard by the judge.

If you establish that the claim denial was in bad faith, you may be able to recover penalties, attorney's fees, and other damages, in addition to the money owed for the medical treatment. It is important to note that simply filing a lawsuit may not be enough, and you should consult a lawyer for specific advice.

In the meantime, work with your medical providers to ensure that any overdue medical bills are not sent to collections while the appeals process takes place.

Pay for treatment out-of-pocket and file a lawsuit for breach of contract

If your insurance company denies you coverage for life-saving treatment, you may be able to pay for the treatment out-of-pocket and then file a lawsuit against your insurance company for breach of contract. Here are some steps you can take if you find yourself in this difficult situation:

Step 1: Understand Your Rights and Options

Before taking legal action, it is important to understand your rights and options. In the United States, if your insurance plan refuses to approve or pay for a medical claim, you have the right to appeal the decision. This right was expanded under the Affordable Care Act, and there are multiple levels of appeal available to you. You can start by working with your doctor and insurance company to provide additional information or supporting evidence for your request. You can also reach out to organizations like the Patient Advocate Foundation (PAF), which provides case management services and financial aid to Americans with chronic, life-threatening illnesses.

Step 2: Gather Evidence and Documentation

If you choose to pursue legal action, you will need to gather evidence and documentation to support your case. This includes your insurance policy or contract, any correspondence with your insurance company, medical records, and evidence of the financial burden you incurred by paying out-of-pocket. Keep a detailed record of all communication and interactions with your insurance company, as well as any relevant deadlines or timelines.

Step 3: Consult a Lawyer

Before filing a lawsuit, it is highly recommended to consult a lawyer who specializes in insurance law, contract law, or health care law. They can advise you on the specific laws and regulations that apply to your case and help you understand your chances of success. A lawyer can also guide you through the complex legal process, ensuring that you take the correct steps and meet any necessary deadlines.

Step 4: File a Lawsuit

If you decide to proceed with a lawsuit, your lawyer will help you file the necessary paperwork and initiate the legal process. In a breach of contract case, you will need to prove that a valid contract existed between you and your insurance company, and that they failed to fulfill their obligations under that contract. You will also need to demonstrate any damages or financial losses you incurred as a result of their breach.

Step 5: Pursue Alternative Dispute Resolution

In some cases, you may be able to resolve the dispute without going to court. This could include mediation or arbitration, which are alternative dispute resolution processes that can help both parties reach an agreement without the need for litigation. Your insurance policy or contract may include a binding arbitration clause, which requires you to resolve disputes through arbitration rather than litigation.

Remember, each situation is unique, and it is important to carefully consider your options and seek professional advice before taking any legal action. The information provided here is general in nature and should not be construed as legal advice.

Contact patient advocacy groups for support and to share your story

If your insurance company denies you access to life-saving treatment, one of the first steps you should take is to contact patient advocacy groups for support and to share your story. Patient advocacy groups are there to help you get access to the prescribed healthcare that you need. They can provide case management services and financial aid to those with chronic, life-threatening, or debilitating illnesses.

One such group is the Patient Advocate Foundation (PAF), a national 501 (c)(3) non-profit organization. In 2023, PAF served patients with over 958 distinct diagnoses. If your insurance plan refuses to approve or pay for a medical claim, you have the right to appeal. There are multiple levels of appeal, and PAF can help you with this process. You can also contact the Patient Advocacy Network, which supports groups like Mended Hearts. Mended Hearts is the nation's largest cardiac peer-to-peer support group, providing support to heart patients, their families, and caregivers for 71 years. They can be contacted at mendedhearts.org, and they encourage people who have been denied access to treatment to get in touch and share their stories.

You can also search online for a patient advocate or patient representative in the hospital where you received care. Many hospitals have patient advocates on staff, and they can help you with overdue medical bills and negotiating medical costs. The VA’s Patient Advocacy Program helps veterans and their families who get care at VA health care facilities. Each VA Medical Center has a web page with contact information for that Center's patient advocate.

Remember, you are not alone in this situation, and there are people and organizations who want to help you get the treatment you need.

Frequently asked questions