Q: I was out of state when I had an emergency situation and was hospitalized. As part of the care, a specialist was brought in because it was necessary. The good news is I am recovering, but my health insurance says the specialist was out of network, so it won’t pay for his charges. This was a life-and-death situation! Can I get the health insurance to pay?
R.C., Seal Beach
A: Glad to hear you are recuperating. With regard to the denial by your health insurer, there are steps that are suggested, but consultation with a qualified lawyer or professional in the health insurance field should be considered.
The denial letter, or explanation of benefits from the health insurance company, probably seeks to justify why the health insurer is not paying, which you can appeal. There may be a time deadline, such as 180 days; check the health insurer’s appeal process (if need be, call there). You may submit a timely written explanation as to why the denial is improper, invalid or should be vacated, which could include a statement from the hospital or physician, or both.
Another option is to require an independent medical review through the California Department of Managed Health Care. This can be done online (hdmhc.ca.gov) or by phone (888-466-2219).
A third choice is to submit a complaint to the DMHC, which regulates most HMOs and some PPOs. If your plan is not regulated by the DMHC, it might be regulated by the California Department of Insurance; if so, you can file a complaint there (insurance.ca.gov). Review your insurance card to see if it identifies which department regulates the health insurer, or you can reach out to either department to inquire.
If these possible efforts are unsuccessful, you have a right to bring a lawsuit.
Q: We are registered domestic partners. Can I can add him to my health insurance here in California?
O.W., Encino
A: Research indicates that you may enroll the domestic partner in your health insurance benefits. The federal government does not recognize domestic partnerships, however, so some people have opted to get formally married.
Office of the Patient Advocate
Here is the online link to the state’s Office of the Patient Advocate: opa.ca.gov. This California office rates health plans and medical groups, tracks consumer complaints, and identifies patient rights and health care resources. You may find helpful information there.
Ron Sokol has been a practicing attorney for over 40 years, and has also served many times as a judge pro tem, mediator, and arbitrator. It is important to keep in mind that this column presents a summary of the law, and is not to be treated or considered legal advice, let alone a substitute for actual consultation with a qualified professional.