News that a former Aetna medical director in California denied benefits to patients without ever reviewing medical records has rocked the medical community and insurance community across the country. The potential that life-saving medical procedures and continued treatment may have been denied without review by a physician means that hundreds or thousands of patients across the country could have suffered worsened conditions or death because their insurance claims were wrongly denied.
If you or a loved one had your insurance claims denied by Aetna or another insurance company, you may be able to sue the insurance company in court. This could mean recovering compensation for the denied benefits, medical treatment for worsening conditions, and even compensation for the pain and suffering or loss of a loved one after a negligent insurance denial. For a free consultation on your case, contact the Philadelphia bad faith and negligent denial of claims lawyers at Reiff and Bily today. Our number is (215) 274-0072.
Suing Medical Insurance Companies for Denying Claims
The problem in bad faith insurance cases is when treatment is already underway or your doctor has deemed the treatment medically necessary, yet your insurance company decides not to pay benefits. Under your insurance policy, there are certain terms and conditions as to when the insurance company may be required to pay-out benefits for procedures. More often than not, any “medically necessary” procedures should be paid for under your insurance policy. While you may still need to pay a copay or some percentage of the treatment costs, your insurance company should pay accordingly when you need treatment. However, your insurance company often makes the final decision of whether the treatment truly is necessary.
Aetna has recently come under fire for rejecting benefits for medically necessary treatment. In the case referenced in the news, a patient with a serious medical condition needed vital care that would prevent hospitalization, worsened conditions, and serious pain and suffering. Under practices Aetna claimed were proper policy, these medical claims were denied by a physician who never actually read the medical records or made any personal investigation into the requested treatment. Instead, the physician given the power to make decisions relied on second-hand information filtered to him through Aetna’s nurses, who investigated the condition, requested treatment, and received patient medical records.
In situations like this, where the person making the decision never actually reviewed the evidence, it is possible that the benefits may have been denied in bad faith, or at least negligently. If you suffered because of negligent or bad faith institutional decisions like this, you may be able to sue your insurance provider.
Damages for Medical Insurance Denial Lawsuits
If you were denied medical benefits when you needed them most, you may face a variety of harms. First, you could be entitled to contract damages for the insurance company’s breach of their promises to you. When a condition is medically necessary or life-saving, most insurance policies demand that the insurer cover the claims. If your insurance company failed to follow the promises made in your insurance policy, you may be entitled to some damages for breach of contract.
More important in these kinds of cases are often the damages you suffer because your condition went untreated. If you needed medical care, but your insurance company denied the medically necessary procedures, medication, therapy, or treatment, your condition may have grown worse. If your condition became irreversible or required extraordinary measures to treat after your condition worsened, the insurance company may be liable for any of these increased treatment costs.
If a loved one died because the insurance company refused to pay to treat their conditions, you could be entitled to a variety of damages for your loss. When you lose a loved one because of someone else’s negligence, there are often unexpected costs like funeral and burial expenses, as well as the emotional costs of losing a loved one. You may also suffer other financial harms from their lost income, inheritances, investments, and other losses. These may all be claimed as damages in a lawsuit against those liable for their death.
When you are actively undergoing treatment for some serious conditions, suddenly stopping treatment can have severe effects. The pain and suffering caused by stopping treatment can leave you incapacitated, unable to attend work or school. The pain and suffering associated with some of these issues may even be worse than the suffering from the untreated condition itself. This may entitle you to substantial damages if your insurance company cut-off medically necessary benefits without good cause.
Philadelphia Lawyer for Bad Faith Insurance Claims
If you or a loved one suffered worsened medical conditions or harmful effects from denied medical benefits or a sudden stop in medical care, contact an attorney today. The Philadelphia injury lawyers at Reiff and Bily can sue insurance companies like Aetna if there is evidence that your medical claim was negligently denied or denied in bad faith. For a free consultation on your case, contact our law offices today at (215) 274-0072.