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Researchers criticize retroactive denial policy of major insurer

People in Florida typically seek out medical care at emergency rooms for acute and worrisome conditions and injuries. To discourage the use of emergency care, the insurance company Anthem launched a policy of reviewing emergency charges and denying coverage if the company deemed the emergency care inappropriate. Researchers who analyzed the outcomes of this policy determined that the insurer could not reliably identify nonessential emergency visits.

The researchers looked at a national database that documented over 100,000 emergency room visits during a four-year period. They applied the rules of the Anthem policy to the cases and found that one in six patients could have been denied coverage. Over 85 percent of the patients in this sample presented symptoms that met Anthem's criteria for payment denial. Large percentages of these patients went on to receive necessary emergency care. The researchers concluded that a policy that allows an insurer to retroactively deny care that might be covered under certain conditions burdened people with fears of high medical bills when they needed urgent medical care.

The American College of Emergency Physicians considered the Anthem policy a violation of the Affordable Care Act. The ACA created the standard that insurers must cover emergency care for symptoms that an average and reasonable person would view as serious.

Insurance companies frequently look for ways to limit what they have to pay on a policyholder's claims. A person who believes they were unfairly denied coverage might want a legal opinion about the situation. An attorney who possesses familiarity with denied private disability claims could review the evidence and insurance contract. If the insurer appears to be responsible for payment, an attorney could manage a breach of contract action. In addition to demanding payment, an attorney could take the insurer to court.

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