$39K Health Insurance Bill Waived for Medically Necessary Testing; AF Pending

When an insurance bill for medical services comes in the mail, many people open the envelope with a feeling of dread, not knowing what percentage of their recent medical treatment will be covered by health insurance and how much they will owe out of pocket. That invoice could be for $20, $250, or even $25,000 or more. When our client opened her mail, she was shocked to see a hospital bill stating she owed $39,000 out of pocket. However, under the terms of her ERISA-governed health insurance plan, she should not have been charged anything. Our team at Donahue & Horrow LLP fought back and ensured our client will not be chased by bill collectors seeking payment of the invoice.

In May 2021, our client was experiencing severe headaches and blurry vision. She first went to a walk-in clinic and was then referred to the Emergency Room. Eventually, she was admitted to the hospital for testing and observation. At the direction of her physicians, our client underwent an echocardiogram with bubble study, an MRI (Magnetic Resonance Imaging), a CTA (Computed Tomography Angiography) and other procedures. No issues were found so she was discharged from the hospital. Less than a week later our client learned that her health insurance claim for the in-patient hospitalization was denied on the grounds that the hospitalization and testing were not “medically necessary,” because no problems were identified. Of course, that claim decision did not make sense because it was only through the hospitalization and testing that the doctors were able to clear and discharge her.

Our client went through the onerous, multi-level appeal process, providing a timeline of events and explained that it would have been below the standard of care for the ER to discharge her without the results from the testing that was performed during the hospitalization. She also explained that she underwent the hospitalization and testing at the recommendation of her doctors, not because she was insisting on testing against her doctor’s instructions. Yet the company that was handling the insurance claim for the ERISA plan still refused to acknowledge that the hospitalization and testing were medically necessary.

When our client contacted Donahue & Horrow LLP, we agreed to file a Federal ERISA lawsuit in the Los Angeles courthouse of the Central District of California on her behalf. In the lawsuit, we asked the Court to affirm that she did not owe the insurance plan any money, and that the plan pay her attorneys’ fees and costs. Eventually, the parties conducted a mediation at which a settlement was reached. While the terms of the settlement are confidential, our client was very satisfied with the outcome.

The attorneys at Donahue & Horrow LLP have decades of experience litigating insurance benefits disputes, including claims made under ERISA-governed disability insurance, life insurance, AD&D and health insurance plans. If you believe that your insurance claim was improperly denied, call Donahue & Horrow LLP at (877) 664-5407 for a free consultation.