If my HMO is denying a test that my cardiologist believes I need, what can I do?

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If my HMO is denying a test that my cardiologist believes I need, what can I do?

My cardiologist believes that I may have a bicuspid valve heart condition baced on CT results. However, my HMO ADOC is denying the esofogial ultrasound test. I suffer from a 5.1 cm aortic aneurism.

Asked on May 25, 2018 under Insurance Law, California

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 3 years ago | Contributor

If you believe that under the terms of your coverage they have to pay for the test, you can sue them for breach of contract for its cost: an insurance policy (including health insurance) is a contract and is enforceable as per its plain terms (I.e. they have to pay for whatever the policy indicates they must pay for). But taking legal action can take time, and you have to take care of your health: if the test is urgent, you may have to pay for it out-of-pocket, then look to get reimbursed or compensated for the cost.


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