Question: My insurance carrier (or HMO) will not authorize a treatment they claim is "not medically necessary" and is "investigational or experimental". What can I do?

Answer: If you are dealing with an HMO, you should be aware that your doctor may have a financial conflict of interest in referring you for treatment for procedures that are new or are not typically provided by the HMO. The first step you should take is to request from the insurance carrier or the HMO an explanation in writing as to the specific reasons and the basis for their denial. You should review your insurance policy carefully with regard to the terms and conditions contained therein, especially with regard to "Exclusions". If you do not have a copy of your insurance policy,  request one in writing, immediately, from your insurance carrier (or HMO). Document all telephone calls or other communications with the insurance carrier or HMO completely. Include the first and last name of every person you speak with, their title, the date and time, and what was said or promised to you. Appeal the denial in writing and ask for an "expedited review".

You may file a complaint with the California Department of Managed Care (if you are dealing with an HMO), or the California Insurance Department, Clain Services Division (if you are dealing with an insurance carrier).

You may be able to "opt-out". Check your policy. If you have a Medicare HMO, most policies allow you to opt-out of your HMO by giving written notice prior to the first of the following month. With some investigation, you may be able to find an HMO that will cover the procedure. However, you must also be careful about pre-existing exclusions to coverage due to pre-existing illness and other restrictions that may preclude you from getting coverage for your condition before opting out.

You may need to contact a health care lawyer who is familiar with these issues. If time is of the essence, don't wait. Get legal help right away!

Question: When is a doctor or hospital liable for "medical malpractice"?

Answer: Under the law of negligence, a health care provider, whether this is a doctor, nurse or hospital, must provide the same level of care as would be required of reasonably prudent health care providers under similar circumstances. When a health care professional or hospital provides substandard medical care that falls below community standards, then those providers may be liable in negligence if their conduct was a cause of harm or "damages" to their patient.

Question: If my doctor asks me to sign an arbitration agreement, do I have to sign it?

Answer: An arbitration agreement usually means that you agree to give up your right to sue in favor of settling any disputes that occur between you and your doctor by means of binding arbitration. Typically, if you signed such an agreement, you will not be able to go to court, but will have to resolve any medical malpractice claims in an arbitration proceeding, and in most cases, the decision of the arbitrator will be binding and final. If you are presented with an arbitration agreement that your doctor asks you to sign, you are not required to sign it if you do not to wish to do so. However, your doctor may not elect to treat you or to continue your medical care under those circumstances, and you may have to find another doctor.

Question: What is meant by "Experimental" or "Investigational" treatment?

Answer: Insurance carriers may exclude from coverage any treatment that they consider "Experimental" or "Investigational". Sometimes this may refer to high-tech and expensive procedures such as bone marrow transplantation or possibly to new drugs such as certain chemotherapy agents. It is important to look at the precise language of the insurance contract as to what the carrier considers experimental or investigational. Different insurance carriers have different definitions. In addition to looking at this language, it is also important to read carefully the list of services that are specifically excluded and/or included in the coverage. Insurance contracts are typically complicated and difficult to understand, and many people never read their contract ahead of time when they are first taking out their coverage. It is only after a problem develops that most people read their contract for the first time.

Question: What is the "statute of limitations"?

Answer: The statute of limitations is a time interval that begins to run usually from the date of injury or death during which you are required to file a lawsuit. For medical malpractice cases, the statute of limitations is typically one year. However, there are exceptions to this, depending on the situation. The importance of the statute of limitations is that if you fail to file your case within this period of time, you may be forever precluded from filing in thereafter.

Question: What is the "HIPAA"?

Answer: HIPAA refers to the Health Insurance Portability and Accountability Act. It is federal legislation that provides for uniform national privacy standards to protect your medical records and information. The "privacy" portion of HIPAA becomes effective on April 14, 2003. All health care providers who utilize electronic billing submissions are required to comply with the provisions of HIPAA.