Posted On June 10, 2014 Personal Injury

Foul Play: Insurance Co.’s Would Rather Pay More and Give You Less

You’ve heard the saying about cutting off your nose to spite your face, but insurance companies take the concept to whole new levels of bizarre. More than once, we’ve seen them essentially keep policyholders prisoners in hospitals rather than discharging them according to doctors’ orders just so the insurance company wouldn’t have to pay for necessary medical equipment. No matter that another day of hospitalization costs substantially more than a back brace – sending the message “You don’t need that!” is apparently all-important.

What It Means to be the Policyholder

Suppose you have been hospitalized following an accident. After the ordeal you have been through, you’re eager to get home, even though you’re still recovering and will continue to need treatment. Your doctors inform you that there’s nothing more that the hospital staff can do for you that couldn’t be done on an outpatient basis while you continue healing. They plan to discharge you with additional medical equipment – perhaps something as simple as a brace for an injured knee or back – that you will use at home.

We’ve seen patients denied all sorts of medical equipment, from back and knee braces to continuous passive motion (CPM) machines, which are devices used after soft tissue surgeries to decrease pain and promote healing. Photo Credit: User:Ravedave, Wikimedia Commons (Creative Commons license).

You wait, maybe for hours, to get the equipment you need and go home. Only it doesn’t happen. Your insurance company has decided that “you don’t need” the equipment your doctors have asked for. The people paying for your hospital stay would rather pay even more money to keep you in the hospital against your wishes and your doctors’ recommendations than pay the relatively small cost of the medical equipment you need.

And you don’t even know how to go about getting the matter resolved.

Why This Happens and How We Fix It

In states with no-fault laws, your own insurance company is the one required to pay for your medical care. But because insurance companies aren’t exactly healthcare experts, they sometimes outsource this aspect of your claim to a medical vendor or PIP (which stands for personal injury protection) vendor. This third party calls the shots on at least some decisions, most notably the medical equipment you are allowed to have.

This puts you, the patient, in a difficult position. Your insurance company probably hasn’t even informed you of the third party handling your claim. You probably don’t have their contact information, and even if you did, there’s little you can do from a hospital room. This outsourcing of medical benefits adds yet another layer of unnecessary complexity to an already convoluted system. The medical vendor is controlling the claim in that they are denying you the medical equipment you need to be discharged, but they’re not the ones actually paying out the money for your bills.

When this has happened to our clients – and it has in several cases – we have ended up calling the insurance adjuster in the case and arguing with them to essentially call off their dogs. The insurance company may not even know of the situation, which means that the process takes even longer and that you are stuck waiting. To make any progress on getting you back home with the equipment you need, we have to inform the insurance adjuster of what its medical vendor is doing and persuade them of the obvious: that it’s unreasonable – and more importantly to them, detrimental to their bottom line – to keep paying for expensive hospitalization instead of just shelling out the little bit of cash necessary for a simple medical device.

Even the “easy” parts of an insurance claim are never truly easy, but give us a call today to find out what your options are!