Denials for Experimental or Investigational Medical Services

A common reason health care claims are denied is that the service is experimental or investigational. Each health insurance policy defines "experimental" differently, but basically the health insurer is saying hat the treatment is not proven to treat the medical condition the patient suffers from.

These denials can be devastating because the patient may have already exhausted other treatment choices. She may have been told by her treating doctor that this particular treatment is the best one for her particular health condition. These are also very hard denials to overturn because what treatments are "experimental" is generally decided by the health insurer without having to defer to the treating doctor's opinion.

CNN posted a recent article about individuals with serious seizure disorders who want to get ablation surgery - a minor brain surgery to treat lesions on the brain causing seizures. The alternative surgery is much more invasive and dangerous. Aetna, the health insurer for the individuals, denied the claims for ablation surgery, stating that it is experimental.

"The laser surgery is approved by the Food and Drug Administration and is widely recognized within the epilepsy community as an effective treatment alternative to open brain surgery, especially when the location of seizure activity can be pinpointed to a specific part of the brain. Dr. Jamie Van Gompel, a neurosurgeon at the Mayo Clinic, disputes Aetna's assessment. He is not involved in Cara's care nor Rittereiser's treatment, but he said Aetna's assessment is wrong."I would not call it experimental at all," said Van Gompel, who is leading a clinical trial on the surgery at Mayo as part of a larger national study. "It's definitely not an experimental procedure. There've been thousands of patients treated with it. It's FDA-approved. There's a lot of data out there to suggest it's effective for epilepsy."

Read the whole article here: "Girl has blunt message for Aetna after her brain surgery request was denied"

Class Action ERISA case against UnitedHealth Group

Medical insurance plans and policies only cover health care that is "medically necessary". Different plans define "medically necessary" in different ways, and health insurance companies often have to come up with some internal guidelines about what type of treatment will be covered for certain conditions, and when different treatment must be sought first.

This is difficult in claims involving mental health and substance abuse. Recently, a class action lawsuit was filed against United Behavioral Health ("UBH") asserting that the guidelines being used to deny claims were not in line with standard medical practice. The plaintiffs allege that UBH guidelines required claimants to receive a lower level of medical care than should have been given to them considering their medical conditions. 

Read more here at California Labor Law News: click for article

What is a Life Waiver of Premium benefit?

A "Life Waiver of Premium" benefit - also called an "LWOP" benefit- is a provision that is commonly included in life insurance policies which waives the premiums normally required to maintain life insurance coverage for insureds who are disabled.

This benefit is extremely important to a disabled person because often based on her medical history, she will be unable to obtain life insurance coverage elsewhere in the free market. She also may not be able to return to work and obtain group term life insurance coverage through an employer.

Each life insurance policy that has an LWOP benefit will define "disabled". The insured needs to meet this definition to qualify to have her life insurance premiums waived. Usually the standard for being disabled is very high - for example, being unable to work in any job for any wages.

If you make a claim for LWOP benefits and the claim is denied, or if you were receiving an LWOP benefit and your benefit is terminated, if your claim is governed by ERISA you have the right to appeal that decision. Even if your claim is not governed by ERISA, your life insurance contract may allow you to appeal that decision to the insurer. You may want to hire an attorney to help with that appeal.

Contact the Law Office of Katherine L. MacKinnon for more information!

NY Times Article: Spouse's Consent is Required to Change Retirement Account Beneficiary

This article in the New York Times addresses the requirement that a spouse be informed of a change in beneficiary and consent to that change:

"WHY does a married person who has certain kinds of retirement accounts have to get his or her spouse’s permission to change the beneficiary of those accounts?

And why does a married person who is about to start receiving a pension have to get spousal permission to select a payment option that will not give the spouse at least half of those benefits for life if the pensioner dies first?

The short answer to both questions is, because the law says so. A longer answer came when President Ronald Reagan signed that law, the Retirement Equity Act of 1984.

“No longer will one member of a married couple be able to sign away survivor benefits for the other,” Mr. Reagan said, explaining that “a spouse’s written consent now will be required on any decision not to provide survivors’ protection.”

Check out the whole article here