Can a health insurer deny the treatment plan of a treating physician?

UPDATED: Oct 1, 2022

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Can a health insurer deny the treatment plan of a treating physician?

About 2 months ago, I had a disk implant in C3-C4 with bone spurs ground

down. My pain remained and I had another scan and my surgeon said there are spurs on the back of my spine that need to be treated from the back and he couldn’t do it from the front previous surgery. I scheduled the surgery but

the insurance company’s third party will not authorize it and instead says that I need to get injections first, even though I have tried these and they have done nothing. Now, the injection doctor is having trouble getting authorization for the procedure. Essentially my insurer is saying that,

Asked on August 20, 2018 under Insurance Law, Florida


SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 4 years ago | Contributor

You can pay for the treatment out of pocket, then look to recover it from the insurer. If you can show that under the terms of the insurance policy--which is a contract--they should paid for this treatment in this circumstance, you can get a court order requiring them to reimburse you. This is the most certain option to get the treatment done, but you must also be able to afford the upfront cost and are not certain of reimbursement later.
You could alternately try bringing a legal action against the insurer on an emergent (think: "urgent" or "emergency" basis) to try to get a court order requiring them to pay upfront. This is a complex legal action to bring; also, you cannot bring it if the policy (which again, is a contract, and so is binding on both parties) states that you must go through some appeals process, or submit to binding arbitration, since in that case, you have agreed conrtractually to limits on your ability to bring a legal action. If you wish to consider or explore this option, bring a copy of your policy to an attorney to review with you.

IMPORTANT NOTICE: The Answer(s) provided above are for general information only. The attorney providing the answer was not serving as the attorney for the person submitting the question or in any attorney-client relationship with such person. Laws may vary from state to state, and sometimes change. Tiny variations in the facts, or a fact not set forth in a question, often can change a legal outcome or an attorney's conclusion. Although has verified the attorney was admitted to practice law in at least one jurisdiction, he or she may not be authorized to practice law in the jurisdiction referred to in the question, nor is he or she necessarily experienced in the area of the law involved. Unlike the information in the Answer(s) above, upon which you should NOT rely, for personal advice you can rely upon we suggest you retain an attorney to represent you.

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