Medically Necessary vs. Reasonable

I live in MI. Surgery in our state must be deemed "reasonable" (to return one's appearance to a pre-accident state {providing it is reconstructive and not cosmetic}.) Procedures do not have to meet the criteria of being "medically necessary".

The doctor that did my previous surgeries (and understood no fault law) knew that the insurance company would pay after the surgery was performed, and had no problem proceeding with them.

He unfortunately, is retiring. I saw him recently, for a consult, and he thought that further (accident related) surgery was in order. He referred me to another physician (who concurred with his opinion.) When the office manager contacted the adjustor, they were told (verbally) that the procedure must be medically necessary.

The insurance company would not, however, put that in writing, (which my attorney says I need in order to make an appointment with him.) I consulted with a third physician who also said that surgery was a "go" in the office, and then said that it would not be possible after speaking with the insurance company.

My claim is "wide open", as the insurance company pays many providers on an ongoing basis. My original physician also says that "late effects" from an accident are common.

I really believe that my insurance company is acting in bad faith and don't know what to do

I don't know if I have any basis for contacting the insurance commission. I don't really know what their role is, and I'm sure I'd need the same proofs there I'd need for an attorney.


Answer:


Hello Cynthia,

Simply because something is cosmetic, it does not mean it is not medically necessary. Thy are not mutually exclusive. Yes, they will play with the terminology, reconstructive vs. cosmetic, but those are terms of art. They are not mutually exclusive. (you can have a reconstruction surgery of your chest, where breast implants are necessary… cosmetic or reconstructive?).

The insurance company will not put something in writing as they are afraid to be bound by their own writing, which at a minimum they are not sure if they owe or have to pay for the surgery (otherwise they would not have a problem documenting the paperwork).

The issue of what the adjuster "thinks" or "believes" is not medically relevant (adjusters are neither, lawyers or doctors). If you have doctors saying that you need this surgery or that is reasonable that you undergo the treatment, the adjuster must, then, have a medical doctor showing contrary opinion.

Do you have a lawyer? Or you where making an appointment with a lawyer? You should consider getting one right now. A lawyer's duty is going to be to get the proper paperwork to document the claim. Sure, you can do it yourself, but you will need a lawyer to get a fair settlement. The later you get them involved, the less that attorney can do to increase your settlement! Cosmetic issues are not the type of claim you want to settle yourself.

You can consult with an attorney by filing the form below.