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When Your HMO Says "No"

You need life saving cancer treatment, but your HMO will not pay. What are your rights? Can you enforce them in time? I recently went to a great seminar on this topic at the Nassau County Bar Association given by my good friend, Susan Slavin. Susan was one of the pioneers of breast cancer litigation in the early 1990’s, and continues today as a leading ERISA and disability rights attorney.
So what do you do when you get an HMO denial? In most states, including New York, you have a right to an External Appeal by an Independent Panel not affiliated with the health plan.. These appeals usually deal with the issues of “medical necessity”, “experimental/investigational treatment” and/or “clinical trials”. In New York, you have to complete the Health Plan’s first level of internal appeal prior to requesting an external appeal. Then you have only 45 days to request the external appeal – and this is a strict deadline. There is also a procedure for Expedited Appeals in emergency cases. In cases involving other issues such as out-of-network expertise, you may have to file a separate ERISA appeal.
The Good News – statistics as of March 11, 2005 show that patients win almost 50% of external appeals. Even better, the appeal process is set up so that most patients don’t need a lawyer. An excellent resource is the New York Attorney General’s Health Care Hotline: 1-800-400-8882. So when your “HMO Says No”, make sure you investigate your appeal rights. You might just win!

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