Joseph Romano Law

I was counsel in a case where my client was a level II/III on the Rancho scale. The family and treating health care professionals believed that the individual could benefit from an in-patient rehabilitation program. The health insurer argued that the individual could not benefit from the coma program since, according to their treatment and practice guidelines, her care was custodial in nature. Most health insurance policies have an internal appeal procedure with their own hand-picked committee people. Pennsylvania, New Jersey, and New York have adopted an external appeal procedure. Usually, the external appeals committee consists of members who are not affiliated with the health insurance company. Prior to the external review, I was successful in using the health insurance contract, bad faith arguments, and medical documentation from the treating doctors to prove that my client could benefit from a coma stimulation/coma awareness program. Also, the insurance company was unable to provide written documentation of their treatment guidelines/practice guidelines or protocols.

Families should be aggressive in fighting a health insurer when they are denied the recommended programs for the patient. Families need to recognize that obtaining health insurance benefits from a managed care insurer, or any insurer, is an adversarial process.