What to do if an HMO denies needed surgery?
Question Details:
I had a bunion surgery on my right foot 1 year ago. In September of this year, my HMO denied my left foot surgery; the reason was "lack medical necessity. The documentation received does not support the need for the service because according to guidelines, a bunionectomy is indicated for patients who meet 6 criteria.My podiatrist submitted all necessary documents and requested another authorization. It was denied again for the same reason. He wrote a letter to the Physician Reviewer, describing my condition and submitted an appeal. It was denied for the same reason. I contacted my HMO and filed a grievance, and it's still pending. Please advise if any lawyer can help me with this. And if not, what my next step should be.
Insurance Law Law Answers
I would seek legal help here on a consultation basis. You may need to sue the HMO to get them to pay for the operation and that may be more expensive than the operation itself. Consumers of HMO's have certain rights. That have the right to be advised of all forms of treatment regardless of whether or not their plan will pay for it; they have the right to appropriate treatment, ask questions, file complaints and file lawsuits. So if you think that a letter from an attorney would make them cringe a bit and possible give in, do it. Try and negotiate a flat fee with the attorney to write the letter and inquire on your behalf. If it does not work then you will need to discuss the suit and that will be hourly (but ask if the fee is recoverable if you will). Good luck.
Related Insurance Law Questions
- Zimmer Hip Replacements May Require Revision Surgery
- The injuries from my slip and fall accident appear to be minor. Why would I want to contact a lawyer...
- New Jersey Family Awarded $11M In Med Mal Case
- Can I file a medical malpractice lawsuit if I am not satisfied with the results of my surgery?
- I underwent surgery that was later found to be unnecessary. Do I have a medical malpractice claim?
Didn't find your answer? Ask.
Top Ranking Attorneys
- Kevin Bessant407 Answers|Points 5850Gold Contributor
- Madan Ahluwalia104 Answers|Points 2900Silver Contributor
- Hong Shen528 Answers|Points 1250Platinum Contributor
- Kenneth Berger25 Answers|Points 1230Bronze Contributor
- Richard Southard76 Answers|Points 1020Silver Contributor
- Glenn M. Lyon, Esq.93 Answers|Points 750Silver Contributor
- Hong Shen528 Answers|Points 26400Platinum Contributor
- Kevin Bessant407 Answers|Points 20330Gold Contributor
- Steven Fromm113 Answers|Points 5430Silver Contributor
- Madan Ahluwalia104 Answers|Points 5170Silver Contributor
- Kelly Broadbent93 Answers|Points 4600Silver Contributor
- Glenn M. Lyon, Esq.93 Answers|Points 4530Silver Contributor
Are you a lawyer?Want to be featured here? Sign up for a free profile and get started today! Click Here