A 47-year-old woman complained to her physician that she had pain in her leg. She had six weeks of physical therapy, which did not help. A medical specialist then ordered an MRI in light of her continuing leg pain complaints over the period of six months. Her health insurance company denied authorization for the requested MRI, and authorized instead six weeks of physical therapy, which the woman had already completed.
The woman’s doctor immediately appealed the denial of prior authorization for the MRI but it took 38 days for the insurance company to review and reverse its prior decision, and to authorize the MRI. The MRI showed that the woman had a fast-growing sarcoma (an aggressive cancer) in her hip. She sought cancer treatment at Memorial Sloan Kettering Cancer Center where a doctor left her a message, “If you had come to us a month sooner, we would have treated you with just chemotherapy. We’ll still use chemo, but first we have to amputate your leg, your hip and your pelvis.”
She endured amputations and had chemotherapy, but she died nonetheless two years later.
The woman filed a lawsuit against her health insurance company and its utilization review contractor, alleging they were both negligent in their prior authorization decisions and by delaying her MRI, but the lawsuit was dismissed. The judge stated that it was for the legislature to address the issue of health insurance companies’ liability for negligently handling prior authorization decisions. The dismissal has been appealed.
It has been reported that a study by the American Medical Association found that more than 90% of physicians surveyed responded that health insurance companies’ requirement for prior authorization for treatment causes delays in treatment, and 30% of the physicians reported that patients suffered serious adverse events as a result. Twenty-four percent reported that delays in obtaining prior authorization for treatment resulted in patient hospitalization. Eighteen percent reported that the requirement for prior authorization has resulted in a life-threatening event or an event requiring intervention to prevent permanent impairment or damage. Nearly ten percent of the physicians reported that insurance company reviews of prior authorization requests led to permanent bodily damage, disability or death.
Eighty-four percent of the physicians reported an increase in the number of prior authorizations required for prescriptions and medical services in the past five years. The Inspector General of the U.S. Department of Health and Human Services found that 73% of appealed denials for medications were overturned.
If you or a loved one were harmed as a result of the denial or delay of prior authorization for medical treatment, you should promptly find a medical malpractice lawyer in your state who may investigate your possible prior authorization claim for you and represent you or your loved one in a case involving the negligent denial of prior authorization, if appropriate.
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