How Health Insurance Companies Deny Benefits
Health insurance companies also wrongfully deny benefits for necessary medicines, therapies and treatments, even though the insureds’ insurance policy provides coverage for these treatments. The carrier will unreasonably decide, without proper medical support, that certain medicines, therapies and treatments are not medically necessary. These improper decisions leave policyholders in the vulnerable position of choosing between their doctor’s advice and recommendations or choosing only those treatments authorized by their carrier.
A health insurance carrier should not be making medical decisions, a person’s doctor or medical provider should be making these decisions. For instance, our firm co-counseled in representing a potential class of severely mentally ill Anthem Blue Cross insureds. With the implementation of the Anthem’s Behavioral Health Outpatient Authorization Program, if a severely mentally ill member needs more than twelve visits a year of psychotherapy, that member must request and obtain authorization in advance, if the member wants Anthem to provide any payment for these sessions, regardless of the member’s diagnosis or recommendations of the members treating provider. The member’s request is then reviewed by Anthem’s “Behavioral Health Outpatient Team” and the company’s “Utilization Management” team.
The Class Representatives allege that this review process is designed to limit each member to twelve visits per year regardless of the seriousness of their illness. Because Anthem does not impose these restrictions on benefits for subscribers and members with other injuries or illnesses, Anthem’s program violates the state’s Mental Health Parity Act.