A recent 5th Circuit opinion exposed what is an all too familiar problem for doctors and their patients: health insurance companies refusing to pay for treatment after expressly authorizing the treatment.
According to the 5th Circuit, this scenario "is reenacted each day across the country" and usually unfolds as follows:
The good news for doctors and patients is that the 5th Circuit has now decided that even health insurance companies that issue group policies, or ERISA policies, which are normally regulated by a more lax federal law, can now be held liable under more stringent Texas Insurance and Consumer laws.
Therefore if you are a Texas doctor or Texas patient whose health insurance has authorized medical treatment only to deny coverage after you received treatment, you may have a claim against the health insurance company who is now denying coverage.
According to the 5th Circuit, this scenario "is reenacted each day across the country" and usually unfolds as follows:
- A patient visits their doctor to receive treatment for a medical condition.
- The doctor diagnoses the condition and recommends a medical treatment plan.
- For some patients the medical treatment plan may require additional treatments, surgery, and medical devices (implants, prosthetic, other equipment.)
- The doctor then contacts the patient's insurance company to see if the requested treatment is covered under the patient's health insurance policy.
- If the patient's health insurance policy confirms that the treatment or device is covered the doctor then proceeds with the treatment.
- The doctor then sends a bill to the patient's health insurance for the services or treatment provided, but the insurance company refuses to pay what it had previously agreed was covered.
- The doctor then may seek reimbursement from the patient who is unlikely to be able to pay for this unplanned financial burden, which can uncomfortably transform the patient/doctor relationship into the debtor/creditor relationship.
The good news for doctors and patients is that the 5th Circuit has now decided that even health insurance companies that issue group policies, or ERISA policies, which are normally regulated by a more lax federal law, can now be held liable under more stringent Texas Insurance and Consumer laws.
Therefore if you are a Texas doctor or Texas patient whose health insurance has authorized medical treatment only to deny coverage after you received treatment, you may have a claim against the health insurance company who is now denying coverage.
