Is it legal for insurance companies to deny doctor referred procedures and/or cut people off?

Question

This is happening all of the time.

I understand why people want the government not to get involved in too many social issues but shouldn't there be legislation that makes this illegal?

Answer 1

It is completely legal.... The insurance companies actually deny life-saving and pain-relieving cancer treatments because of the price. Many people have died from these denials because physicians will not provide the services for free (and they shouldn't; the materials are often very expensive).

It amazes me that a lot of people completely ignore (and that our lawmakers allows this to happen) this. I have known people who work in cancer treatment centers for children... a lot of leukemia treatmants are very expensive and often experimental. Responsible parents with insurance have had to beg for money from churches or anyone for treatments. This is not a exaggeration. Everyone thinks that these things only happen to the uninsured but these things happen to the outright denied (after many years of paying premiums).

Answer 2

First of all, they can't "deny" access to health care. All they can do is deny *paying* for it. As we move more towards socialized medicine and see the lines at the clinic get longer and the time spent with a physician necessarily shorter (was anyone else in an HMO?), we can expect more of this. What will happen is that those with the means will buy supplemental policies or pay out of pocket, the rest will be relegated to whatever the government provides. This is the same government, by the way, that sponsors FEMA ... That rant probably doesn't help you, but this may: most insurance companies have a review process for just this sort of complaint. If you're getting nowhere, there, most states also have an ombudsman. Good Luck.

Answer 3

An insurance company is a private business. It is licensed by the state, when you disagree with their procedures, you contact the State Bureau of Insurance and start the review process.
It does happen all the time, it happened to me so I know exactly what goes on.
I had three doctors recommending an operation be done a certain way. The insurance company refused, citing their policies. They never sent a copy of that policy. The booklet that they send you with the policy only gives you the high points, not the nitty-gritty what they aren't going to allow. So I went to the State, it took four months to get the policy sent to them, and then to me. It turned out that the policy stated that my condition was exactly covered as first requested. If I hadn't fought them I could have put my life at risk. They frequently say no so they can save money, their main concern is profit, not your health. Its a sickening shame what they pull on us.
I knew how to fight them, but thousands of the ill and elderly don't, or become confused, or don't understand how dangerous for their particular case a certain cheaper procedure can be. I did.
Our company had so many complaints about Aetna that they switched providers at the end of the year. Our system needs an overhaul, sticking our heads in the sand does no one any good. I'm open to new ideas, but I don't seem to get any worth a darn. Really, not from either party.

Answer 4

Yes, what people misunderstand is that insurance companies do not provide health care, they provide insurance which is a financial product, like homeowner's or car insurance. Most people don't have the slightest idea what is and is not covered by the health insurance and when they find that they don't have coverage for certain services (pain management, mental health, advanced procedures, etc.) they complain about the insurance rather than asking for a covered service. If the patient would know what their insurance covered they could work with their referring physician to ensure that they had a covered diagnose/treatment plan rather than finding out after the fact that they weren't covered.

Be honest, do you know what is included in your health insurance? Or do you assume that either a) you won't get sick anyhow, or b) that it covers everything you might have done?

Answer 5

The fact that a doctor suggested a procedure does not mean that an insurance company has to pay for it. It may not be a customary procedure or test. It may be overpriced and fall outside of the insurance companies qualifications for reasonable and customary. Or it may be something which required pre-authorization, or pre-cert. If you did not follow the stipulations for this, they will deny payment.

Answer 6

The way some of the insurances are set up, administrators (not doctors) are making the decisions to allow or deny medical procedures. Doesn't make sense to me, unless they're only in the business to make money.

Answer 7

Yes. If you have employer provided health insurance, the insurance company can decide what is "reasonable and customary" when it comes to deciding which procedures and drugs they will pay for. Universal single payer health care would correct this problem.

Answer 8

Yes it's legal if it is in their policy and the way those things are written up you need an attorney present to decipher all that mumbo jumbo that the average person can't comprehend. They say to always read the fine print but they didn't tell us how to decode it. Thats the part that should be illegal. Just tell us what you're going to pay for and what you won't pay for in simple english.

Answer 9

It depends on the circumstances. It would be necessary to read the insurance policy to determine what is covered. Insurance is a contractural matter, not a legal one. If you have not been treated fairly, file a complaint with your state's insurance commissioner.

Answer 10

Yes, it is, that is why you need to shop around for a good Insurance Company.