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  1. #1
    Join Date
    Jun 2008
    Posts
    9

    Default Denial of Service

    My question involves medical malpractice in the state of: California. My daughter has suffered a significant knee injury. Her doctor suspects a torn MCL and meniscus. The request for an MRI has been denied because she needs to follow a protocol of x-rays first and then 6 weeks of rehab. He tried to fight it but they said there is no appeal.

    She can barely walk on this injury after a week. How can an insurance company deny a request from a doctor and force a patient to go through 6 weeks of painful and harmful rehab before she can get the care she needs?

  2. #2
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,521

    Default Re: Denial of Service

    Because contrary to popular belief, the law does not require insurance carriers to violate their policies.

    If the policy states that a particular procedure has to be followed before they will pay for a type of treatment, then they are not responsible for paying if you do not follow the procedures. Nothing in the law says that they have to pay for everything that the doctor says is necessary if it is not covered under the plan.

  3. #3
    Join Date
    Jun 2008
    Posts
    9

    Default Re: Denial of Service

    Quote Quoting cbg
    View Post
    Because contrary to popular belief, the law does not require insurance carriers to violate their policies.

    If the policy states that a particular procedure has to be followed before they will pay for a type of treatment, then they are not responsible for paying if you do not follow the procedures. Nothing in the law says that they have to pay for everything that the doctor says is necessary if it is not covered under the plan.
    I am concerned that any rehab will exacerbate the condition. The medical people all disagree with the insurer. Who would be responsible if their protocol makes the condition worse?

  4. #4
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,521

    Default Re: Denial of Service

    I don't think you're understanding the point, here.

    The insurance carrier is not responsible for paying for any and all care that is required. It is responsible for paying what it says in the plan will be covered, under the circumstances described by the plan.

    What medical care your daughter receives is between you and her doctor. What the insurance company will PAY FOR is determined by the policy. They are NOT responsible for paying what the contract excludes, and they are NOT liable if you opt not to have the treatment unless they pay for it.

    Let me put it this way. They are not telling you what care she can receive. They are telling you what care they will pay for. You are perfectly free to have any treatment you and your doctor think is necessary, but the insurance carrier will only pay for what the contract says.

  5. #5
    Join Date
    Jun 2008
    Location
    seattle
    Posts
    4

    Default Re: Denial of Service

    This is an extremely frustrating situation and it occurs quite often with orthopedic injuries.
    Doctors become frustrated because they the treatment is indirectly managed by the insurance company. What we think is the best treatment doesn't matter. I don't think she'll further injure the knee as long as PT knows about the situation and restricts appropriately. Good luck.

  6. #6
    Join Date
    Jun 2008
    Posts
    9

    Default Re: Denial of Service

    She doesn't have a physical therapist because no one authorized one. After the third denial, her physician referred her to a specialist and she will finally see him today, August 1. She injured the knee on June 22 and still can only bend it slightly, so exercise is out. She is a semi pro soccer player and, needless to say, missed almost the entire season and will likely miss another at this rate. No one I have spoken to has ever heard of such a situation before. I am beyond frustrated to see my daughter have to endure this much pain and inconvenience because of an insurance company's attempts to cut costs. I know it's policy but it is cruel.

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