Does anyone gather statistics or investigate health ins. companies for denying necessary tests?

October 16, 2011 1:41 AM

Is there an agency or organization to complain to when an insurance company denies a test that results in extended but easily avoidable pain & suffering?

My 32 year-old brother walked for over two months on a broken hip (in excruciating pain) because his insurance company denied the MRI requested by his doctor after a negative ultrasound and unclear X-Ray. A 2nd MRI request was eventually approved, the hip break identified, and surgery to insert screws into his hip followed. He is now pain-free.

Does anyone gather statistics or investigate health insurance companies for denying necessary tests? (I doubt my brother wants to bother dealing further with the insurance company--he doesn't even know I'm asking this question--I'm just wondering if there's someone I could/should write a letter to, or something.)

posted by xyzzy to law & government (7 answers total)

Insurance ombudsman.
posted by aeschenkarnos at 2:38 AM on October 16, 2011

The state division of insurance will have someone to take this to.
posted by MarkAnd at 2:44 AM on October 16, 2011

google your brother's state + "department of insurance"
They regulate insurance in individual states.
posted by smalls at 4:57 AM on October 16, 2011

NYS Department of Health Complaints and Appeals

posted by mlis at 7:22 AM on October 16, 2011

As mentioned, state insurance regulators are his best bet. However, he needs to determine how much time he wants to put into expecting "government" to advocate for him with "big business". Sort of like asking the fox to protect the chickens from the wolf. Time invested in healing might be more beneficial.
posted by HuronBob at 7:22 AM on October 16, 2011

Awesome, thanks everyone.

@HuronBob: I'm a deep cynic and therefore don't actually expect anything to happen or change, but I figure sending a letter wouldn't kill me. At the very most someone might file it away and use it to generate statistics or something vaguely useful to a future victim of this practice.
posted by xyzzy at 10:22 AM on October 16, 2011 [1 favorite]

You should absolutely send a letter. States track and make available numbers for both complaints and appeals that go past the insurance company process. Those numbers are used to rate insurers -- for example, by the NCQA in their insurer report cards.
posted by MarkAnd at 5:56 AM on October 17, 2011