Anthem BCBS Denied Medical Claim

[gusrithgen]

Jurisdiction

Nebraska

On 4/11/2015 I began experiencing stroke-like symptoms and my wife took me to the ER. They ran a bunch of tests MRI CT etc. The medical claim for that visit was approved. On 4/15/2015 I began experiencing the same symptoms and they ran more tests MRI CT etc and my claim was denied stating itwas medically unnecessary. I have gone through the Blue Cross Blue Shield internal and external appeal process. The first two internal appeals upheld the decision of denied and the external appeal also held up a decision of denied. The reason in all three cases stated medically unnecessary. BCBS is not being consistent Or the hospital ordered tests that were medically unnecessary. It has to be one or the other but it cannot be both. What legal action can I take against the hospital or the insurance company?

 

[cbg]

Probably none.

 

[Betty3]

Probably no legal action. However, some states have a state appeal process if your appeal with ins. co. is denied. You can check with your state ins. commission to see if there is one in your state.

 

[adjusterjack]

What legal action can I take against the hospital or the insurance company?

Nothing against the hospital. The hospital is not a guarantor of your insurance coverage.

However, you may be able to sue your insurance company for breach of contract. No guarantee there but you can consult an attorney who specializes in suing insurance companies and has had some success against medical insurance.

 

[cbg]

While the OP can certainly investigate I think it's unlikely to fly in this case. The tests were taken and showed no results. Taking them a second time is not necessarily covered in the same way, or at all.

 

[Betty3]

I agree cbg that in this case the ins. co. "probably" will prevail.