What You Need to Know About Independent Medical Review
In a previous post, we talked about using an insurance company’s internal appeals/review process if the insurer denies your claim or request for treatment when you think they should have approved it (see Why an Internal Appeal is a Really Big Deal). There, we noted how a federal law (ERISA) that governs employer-sponsored health plans requires that insurers have such a procedure in place and further requires policyholders to use that procedure before they can file a lawsuit. We also noted how important those appeals are because if you later go to court, the arguments you want to make or evidence you intend to give can be limited by the record you created at the administrative level.
It’s not just ERISA plans that force you into the insurance company’s internal appeal process. Many state laws have similar provisions. For example, let’s look at the Independent Medical Review (IMR) process required by California insurance law. If you are in another state, check out your state’s department of insurance or call an experienced insurance law attorney who practices in your state.
Appealing Claim/Coverage Denials in California
When insurance companies deny a claim for coverage in California, they are required by law to give the policyholder an explanation for the denial and further inform the insured about the process to appeal the insurance company’s decision. This process generally includes an internal review or appeal (or maybe both) within the insurance company’s system, as we discussed in the previous post. If, after these steps, the carrier still denies your claim, you can ask for an Independent Medical Review with the California Department of Insurance (CDI).
In an Independent Medical Review (IMR), the CDI will select independent medical professionals to review the medical decisions by the insurance company and give their opinion on whether the insurer’s decision is justified. The CDI will require the insurance company to hand over all the documents and medical records it used in making its decision. The ultimate decision made by the IMR is binding on the insurance company.
The IMR is not available for all insurance disputes. Instead, it is limited to situations when the insurer is denying coverage of a requested medical service in one of these three areas:
- The insurer says the treatment is not “medically necessary”
- The insurer says the requested therapy is “experimental” or “investigational” as it relates to the medical condition in question
- The insurer is denying a request for emergency or urgent medical services
Denials based on medical necessity or experimental or investigational treatment are some of the leading reasons insurance companies use to deny claims. Often, these denials come out of blanket policy bulletins and don’t involve an individual assessment of the need for the service in the particular patient’s case. Insurance law firms that represent patients have been successful in fighting insurance companies that use these reasons unfairly and inaccurately.
Note that you don’t have to go it alone. The CDI allows you to designate a person to be your IMR assistant and act on your behalf. Your doctor can also join you if you so choose. It’s important to know that you only have six months from the insurer’s decision on your appeal to file an IMR. Going through the IMR won’t prohibit you from filing a lawsuit later, but skipping the IMR could impact your ability to sue. If you haven’t already used a lawyer for the internal review process (something we recommend), be sure to speak with one before the time to request an IMR expires. You want to keep all your options open and pursue the most promising path available. Oh, in case you were wondering, the IMR is free to you. The insurance company pays the cost.
Still Not Satisfied? Grab a Lawyer and Go to Court
If the IMR process does not yield positive results, the next step might be to file a lawsuit in court. If successful in court or an out-of-settlement, you can recover compensation for all of your out-of-pocket expenses and make sure your claim is covered. If the insurance company was acting in bad faith when it denied your claim, you could recover additional money damages for pain and suffering and emotional distress, and even punitive damages in some instances. Get hold of a good insurance law attorney who will take your case on contingency and only charge a fee if they are successful in recovering compensation on your behalf. Most reputable insurance lawyers offer a free consultation, so it won’t cost you anything to find out if you have a case and how best to proceed.
