Can a person get an insurance company to cover a medical procedure that was done without insurer's approval?
Question Details:
Daughter (22) has insurance. Got flu; later difficulty breathing. Sent by school infirmary to ENT. ENT sent daughter for CAT scan prior to hospital admitting - worried about symptoms. Insurance said it would take up to 3 hours (or next day for approval). Daughter signed a waiver to have scan. Diagnosedwith bacterial tracheitis, admitted, then diagnosed with H1N1. In isolation for 2 days. Insurance denied CAT scan because of "shortness of breath"ICD-9 code. With additional Dr. info, can I get insurance to pay for scan, even though we went ahead without pre-approval?
Insurance Law Law Answers
There is no general answer--it depends on the terms of your insurance policy, which is a contract between you and the insurer. If the policy, for example, contains the common (but not necessarily universal) exception that emergency treatment does not need to be pre-approved, then it may be possible to argue that under the circumstances, this was an emergency. However, without an emergency-style exemption, then probably no, you can't get it paid for. From what you write, the real issue is that your daughter went ahead with the scan without waiting for the approval process. That means that the medical code or description is not the problem--it's the fact that she circumvented the normal process.
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