Attorney to fight health insurance company?
I am wondering if there are any options for dealing with an insurance company denying a procedure. My mother (who lives in the South Bay) is being treated at Stanford for metastatic stage 4 breast cancer. She has a brain tumor, and her doctors have all recommended she have it treated with a type of radiation called a Cyberknife (she has had this treatment once before and it worked very well). Her insurance company (Valley Health Plan) sent her chart for a second opinion (by a doctor who has never actually seen or met my mother) and they concluded the brain tumor does not need to be treated. My mother's actual doctors disagree. She is filing a grievance with her insurance company--but I think she is going to need legal support to help challenge her insurance company.
It feels a little bit like her insurance company is giving up on treating her because her diagnosis is terminal. However, at the moment she is still a very capable person and we are not ready to give up on treatment--especially when her doctors aren't recommending that.
I have no idea where to start with this. If anyone can recommend a lawyer that works with patients against insurance companies or has any other advice that could help get my mom the treatment she needs, I would appreciate it.
Thank you.
Parent Replies
I am so sorry you are going through this. No advice on a lawyer, but the podcast "Arm and a Leg" recently had a couple episodes with a women who professionally fights insurance denials. There are a couple episodes with her where she provides concrete advice on next steps. This podcast has a lot of information about insurance, in general too. Here is the first episode: https://armandalegshow.com/episode/insurance-warrior-part-one/
Have you contacted the Department of Managed Health Care? Did so if your mom is not on Medicare. Fill an urgent complaint.
Law office of Scott Glovsky https://scottglovsky.com
Office is in soCa but they file complaints and lawsuits throughout CA. I gave personal experience w firm.
I'm sorry that you and your family are going through this. Insurance companies are the worst. The next step is to file a complaint with the California Department of Managed Health Care. They oversee all insurance companies in California and they will get an independent medical review that will review what is needed and make a determination. You can file the complaint online here: https://www.dmhc.ca.gov/fileacomplaint.aspx In my experience, they will contact you quickly to start the process.
Legal Assistance for Seniors in Oakland has a division called: Health Insurance Coverage Advocacy Program (HICAP).
The health care manager (Brown and Toland) denied us. We stopped there, but the information I looked up, was that the next thing was to file a grievance with the state, and that a person could request an urgent 3-day response. I just wanted to back up their advice, because I think it is correct.