The Right to Appeal When Treatment is Denied Under the Affordable Health Care Law

 
One of the most difficult aspects of the current healthcare system is when a specific course of medical care or treatment is recommended by a patient’s physician but not authorized by the patient’s healthcare provider.
 
At the present time, many healthcare insurance companies typically get away with egregious denials of these types of requests when healthcare coverage is provided by the patient’s group employment plan offered by their employer. These types of benefit plans have been protected by Federal Law named ERISA which was interpreted by the Federal Supreme Court to limit the liability of medical insurance carriers. Under this interpretation, care providers are only liable for the costs of the medical care wrongly denied regardless of the impact that the denial would have on the patient’s health and even life expectancy.
 
Under the existing law, if a request for an MRI Scan is denied, preventing the physician from diagnosing a brain tumor which eventually results in the untimely demise of the patient, the only damages which the family can recover is the costs of the MRI Scan itself.
 
At the present, it is unclear what if any legal recourse the patient or their family would have when medical treatment is wrongly denied under the new Affordable Care Act. However, there are certain provisions of the Act, which provide some protection, to protect against treatment wrongfully denied.
 
Section 2719 of the Affordable Care Act provides an appeals process for an enrollee to have their file reviewed and to present evidence and testimony as part of the appeals process and to receive continued coverage pending the outcome of the appeals process.
 
Additionally, there is a provision for an external review process that at a minimum includes the consumer protection set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners that is binding upon each of the plans participating in the exchanges.
 
Furthermore, health insurance Ombudsman Programs are required pursuant to Section 2793 requiring each State to establish the office of health insurance consumer assistance or healthcare insurance ombudsman to assist in the filing of complaints and appeals when medical benefits are improperly rejected or denied.
 
At the present time, it appears unclear regarding what other rights a patient would have who receives coverage under an individual policy purchased through a joint insurance exchange. The answer to that question should be forthcoming over the next few months.
 
If you or a family member has been wrongfully denied medical care or treatment, please contact attorney Gary Sernaker to discuss your rights and options under California Law.
 
Photo Credits: Joe Crimmings Photography, Flickr.