In the first lawsuit of its kind, the California Medical Assn., three county medical groups, four surgery centers, more than 60 individual doctors, and one patient are suing insurer Aetna Inc. in Los Angeles Superior Court for threatening to deny benefits to policyholders who go "outside the network" for treatment, even though their policies allow out-of-network treatment. The lawsuit also alleges, reports Chad Terhune of the Los Angeles Times, that Aetna threatened doctors and health care providers with termination of their contracts if they continue to make outside referrals. See, "California Physicians Sue Aetna Over Out-of-Network Referrals," http://articles.latimes.com/2012/jul/04/business/la-fi-aetna-doctors-lawsuit-20120704. Aetna contends that health providers are trying to increase their profits by referring patients to facilities they own without telling patients about the conflict of interest.
"Aetna is putting profits ahead of patients' health and safety," Rocky Delgadillo, chief executive of the Los Angeles County Medical Assn. and former Los Angeles city attorney, told the Times. "I hope Aetna sees the light and stops these actions."
It isn't news that an insurer puts profits ahead of their policyholders' health, but it's refreshing to see the medical profession challenge insurers' bullying and threats because they don't want to pay for medically necessary treatment they believe is too costly. For many illnesses – brain injuries and eating disorders in particular – facilities in-network in some parts of the state are inadequate or non-existent to treat the disease or injury. Going out of network is simply the policyholder's only chance for recovery or regaining the best quality of life they can achieve.
Yes, these facilities cost a lot of money, but isn't that why people purchase health insurance: to get the best care available. Few people pay premiums month after month with the expectation of sub-standard care because their health plan doesn't offer or won't pay for treatment that can actually heal them.
Experts say disputes over benefits will only increase as demand to cut costs to comply with the Affordable Care Act rise during the next couple of years. Often, however, policyholders can win disputes with their health insurers, particularly with policy language and California law on their side. If you are involved in a benefits dispute with your health insurer, contact us at (800) 446-7529. We can help.