Claim Denial for Discharge AMA

[Mark Ritchie]

Jurisdiction

California

I have a claim being denied due to discharge against medical advice. The ERISA SPD states the following

Non-Compliance. All charges in connection with treatments or medications incurred due to the patient's non-compliance with or discharge from a hospital or skilled nursing facility against medical advice.

Incurred An expense for a service or supply is incurred on the date the service or supply is furnished.

No matter how I look a at this my reading of this is that charges which are the result of the non-compliance are not covered.

Please advise.

 

[Zigner]

I concur with your interpretation (and would have told you the same thing even if you had not written it out). Beyond that...did you need more advice? If yes, then please tell us what you would like advice on.

 

[army judge]

No matter how I look a at this my reading of this is that charges which are the result of the non-compliance are not covered.

Bingo, mate.

You completely understand the ramifications of seeking treatment and walking away AGAINST MEDICAL ADVICE.

 

[cbg]

My advice is that you pay the medical bills you incurred since it would appear that the insurance carrier has no liability for them.

 

[Mark Ritchie]

I concur with your interpretation (and would have told you the same thing even if you had not written it out). Beyond that...did you need more advice? If yes, then please tell us what you would like advice on.

This is being presented as a
Being that every patient is supposed to have the right to participate in the planning, execution, suspension, or refusal of health care are any laws being violated if medical coercion is being used to influence these decisions and what statutes would these be.

 

[Mark Ritchie]

My advice is that you pay the medical bills you incurred since it would appear that the insurance carrier has no liability for them.

How do you come to this conclusion?

 

[Tax Counsel]

This is being presented as a
Being that every patient is supposed to have the right to participate in the planning, execution, suspension, or refusal of health care are any laws being violated if medical coercion is being used to influence these decisions and what statutes would these be.

You generally have the right to refuse medical treatment or undertake some kind of alternative medicine treatment (e.g. tribal remedies, prayer, etc), assuming of course that you are a competent adult. Thus, if your doctor recommends having a cancerous growth removed, you have the right to say no. The doctor cannot strap you to an operating room bed and force you to undergo the operation. You can instead try to treat that cancer with some kind of non traditional healing (so long as it doesn't involve something that itself violates the law, like say sacrificing a child on an altar).

But having that right does not obligate insurers to pay the bills for the choices you make that go against medical advice. People who go against medical advice often end up worse, not better, and the insurer doesn't want to be on the hook for the increased costs of dealing with that. And no law forces them to cover that. They are only obligated to cover what the contract of insurance says they will cover; if the policy does not cover alternative treatment or pay for adverse effects of going against medical advice then you end up paying that cost yourself.

As for laws on coercion, it depends on what kind of "coercion" you have in mind. It is illegal for someone to make you do something by illegal use of force (e.g. putting a gun to head, beating you up, etc) or by threatening to do so. It is illegal to use some other illegal or improper means to make you do something, like engaging in blackmail/extortion. Simply doing or threatening something that you don't like is not illegal coercion. They can use legal means of persuasion in an effort to get you to go along with medical advice. It's then up to you if you want to risk those consequences, like not having bills covered.

So exactly what kind of coercion is involved here?

 

[cbg]

How do you come to this conclusion?

An insurance policy is a contract. It obligates the insurer to pay when, and only when, the conditions outlined in the contract are met.

One of the conditions, as you have provided, is that the patient comply with medical advice. That's the patient's end of the contract to meet. If the patient does not comply with medical advice, they have not met their burden. The contract specifies that if the patient does not meet their burden, the insurer is freed from theirs.

Based on the language that you yourself provided, when the patient does not comply with medical advice, the associated bills are excluded. You will never find a theory of law under which an insurance carrier is obligated to pay bills that are excluded as part of the contract.

 

[Mark Ritchie]

So exactly what kind of coercion is involved here? [/QUOTE]

Tax Counsel,

Let me start by saying thank you taking the time to provide your detailed response. Not everyone is so thoughtful.

To clarify my original post. I am being denied for charges that were furnished prior to the DAMA, not for charges that were the result of the DAMA.

I'll use the following example to explain why I believe this to be coercion:

'I spend 3 weeks in the hospital incurring $200k of charges, for a compound fracture of my arm. The doctor comes in an tells me he recommends removing a kidney to allow for full recovery. I don't believe my kidneys have anything to do with my broken arm that is in traction. The doctor insists this is necessary. I am now at appoint where I need to make a decision. To either allow my kidney to be removed or face bankruptcy by being non-compliant should the doctor decide to place the legally defensive language of DAMA into my record." At this point I am not making my decision based upon what I deem is best for me but have the financial threat by a third party influencing my decision.

I could understand if say, I DAMA and I am told I could lose consciousness and should not drive. Then leave anyway and jump in my car and run into a tree get life flighted to a hospital for emergency surgery to save my life. In this scenario it is clear how my decisions have resulted additional costs which could have been avoided if I had been compliant.

In my case the non-compliance was not staying in the hospital overnight to have a test run the next day, which I returned the next day to perform the test. Results were negative.

I hope you understand I have intentionally made these examples extreme to avoid the discussion spiraling into the realm of it depends.

The language of the provision appears to be very specific in that the does not cover Medications or Treatments "Incurred Due To Non Compliance". I'm trying to understand how this could be interpreted to mean a retroactive denial of coverage. How far back can they go 3 days , 3 weeks, 3 years?

The Nation Patient Advocate Foundation is stating that DAMA is not a grounds for denial of coverage. I

I found this study which looked at over 46000 admissions and DAMA and found no evidence of insurance denial for DAMA.

Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend?

It would very easy for an insurer to have a clause that states:

Discharge Against Medical Advice: If you discharge AMA we don't pay anything incurred during that visit.

Could it be that this language is not in insurance for a reason? I would be very interested in any information that references case law, legislation, etc. preventing this form of denial.

Additional information: The plan is ERISA has a Discretionary Authority Clause, but the Insurance company and the Employer are both headquartered in Illinois which has legislation banning such clause in insurance.

Thanks

 

[cbg]

I hope you understand I have intentionally made these examples extreme to avoid the discussion spiraling into the realm of it depends.

Perhaps you might want to make your example less extreme, as the removal of a kidney as treatment for a broken arm would never pass the hospital ethics review board. In fact, I suspect that in the highly unlikely event that it actually happened, the insurance carrier itself would absolve you of any responsibility for the associated bills.

On the other hand, there could well be a valid medical purpose in keeping you overnight before a test. Even if the final result was that the test was negative.

 

[army judge]

On the other hand, there could well be a valid medical purpose in keeping you overnight before a test. Even if the final result was that the test was negative.

Quite correct you are, ma'am.

For example, patients that will undergo certain gastric exams are kept overnight to monitor their liquid and food intake.

Another example might be those waiting to undergo an MRI.
Patients again have their liquid and dietary intake monitored.

Some patients might receive certain drugs that require their health to be observed while receiving those meds.

Other patients might be required to have blood drawn regularly, urine and fecal output monitored, recorded, and even tested.

Whatever the reason, the attending physician's advice shouldn't be disregarded, unless the patient is prepared for the financial ramifications of her/his decision(s)!