Some insurance carriers delay or deny a patient’s medically necessary care, despite recommendations by doctors or other health professionals, in order to reduce costs and increase profits.
A delay or denial can happen to anyone with a health care plan. However, firefighters are particularly vulnerable because, as government employees, their plans are not protected by the Employee Retirement Income Security Act of 1974 (ERISA) in the United States.
Protections for firefighters
Without the protections of ERISA, insurance carriers can more easily get away with delaying or denying claims without significant pushback – which can ultimately harm the patient and lead to exacerbated injuries. However, some states, such as Florida, have protections in place so that firefighters and other similarly situated workers can seek legal recourse.
We discussed the issue with Leslie M. Kroeger, a partner at the law firm Cohen Milstein Sellers and Toll. She serves as co-chair of Cohen Milstein’s Complex Tort Litigation practice. Kroeger has also led several managed care abuse cases, spoken at conferences on this topic, and currently serves as President of the Florida Justice Association.
TheBigRedGuide.com: What is "managed care abuse" and why is it an important topic?
Kroeger: Managed care abuse occurs when your medical insurance provider or HMO breaches its fiduciary duty or contractual responsibilities to you by denying you access to medically necessary care or medication in violation of its healthcare policies and the law. It is often the result of the company prioritizing cost-cutting and profit-making over patient care. This obviously puts the health of the patient at risk. Cohen Milstein has extensive experience litigating managed care abuse claims against insurance companies and HMOs.
The result of the company prioritizing cost-cutting
BRG: How are firefighters particularly at risk? What are the solutions?
Kroeger: The health and welfare of firefighters is paramount as they need to be physically fit to perform their life-saving duties. Firefighters also have a dangerous job that can result in physical and emotional injury. They should be able to get any and all medically necessary treatment allowed by the terms of their health insurance policy without having to fight for them after being wrongfully denied by their insurance carrier.
BRG: How should firefighters seek proactively to address the issue of managed care abuse (short of filing a lawsuit)?
Kroeger: If a firefighter believes he or she has been wrongfully denied medical care or medication, the first step is to follow the appeal process outlined by the health insurance policy. This will usually require placing a call or writing a letter challenging the decision within 30 days of the denial, but one should check the terms of the policy to follow the procedure that applies in a particular situation. It’s important to keep notes on all action taken during the appeal, including who you spoke with, when, and the details of the conversation. It’s also vital to work with healthcare providers to insure they too are following through with the insurance carrier.
BRG: What are the legal remedies available to address the problem?
Kroeger: If your appeal to the insurance company is denied, you may be able to file a lawsuit against the company. You should call an attorney to discuss your particular situation.
Firefighters are increasingly exposed to chemicals and other toxic materials
BRG: What other potential issues/challenges do you see related to medical care for firefighters, especially those injured in the line of duty?
Kroeger: Firefighters are increasingly exposed to chemicals and other toxic materials while doing their jobs. This will continue to place them at risk for additional medical problems, thereby increasing the need for medical care.