In an Emergency
Be Ready To Fight!
From the publishers of the New England Journal of
When a health plan blocks essential treatment by refusing to
authorize it, there's no time to wait around for an internal appeal to be resolved. In
life-or-death situations, consumers have two courses of action.
State regulatory agencies can intervene immediately
in those cases. Pamela Gaume of the California Department of Insurance recalls that her
department, which regulates fee-for-service health plans, got involved immediately to
force an insurance carrier to authorize a critical part of a bone-marrow transplant
The insurer had tried to drop the patient's coverage
in a "bureaucratic dispute over whether the extension of benefits for total
disability ran concurrently with the coverage period mandated by COBRA (the federal
Consolidated Omnibus Budget Reconciliation Act)," Gaume explains, demonstrating the
bloodless technicalities that put lives at stake.
The regulators that govern managed care will
The consumer's second option is to find an attorney
to get a court to order treatment. Washington, D.C., lawyer Jacqueline Fox has used this
recourse for clients a number of times. "It doesn't automatically mean the insurance
company has to pay for the claim," she explains, "but they can't block you from
getting a procedure." It's not difficult to persuade judges to issue court orders,
she adds. "When all hell is breaking loose and we get the doctor to say this
patient is going to die without the treatment, most judges don't want that blood on