Clifton, AZ asked in Health Care Law and Insurance Bad Faith for Arizona

Q: What are our options if our health insurance denied a $28,000 air ambulance claim stating it was medically unnecessary?

In August 2021, my spouse was evaluated in our rural/local emergency room. It was determined he had Covid pneumonia and needed to be admitted but the hospital was full. A bed was found in a location 3 hours away. We have emergency helicopter insurance, so they were arranged for the transport. But my spouse was too broad shoulder to shoulder and he was sent by air ambulance instead. Our health insurance is provided through our employer. The insurance carrier determined it would not have been detrimental to his health to be transported via ground ambulance instead of air ambulance and denied the claim. What are our options now?

1 Lawyer Answer
Tim Akpinar
Tim Akpinar
  • Insurance Claims Lawyer
  • Little Neck, NY

A: An Arizona attorney could advise best, but your post remains open for three weeks. Given the $28,000 at stake, this is probably something on which you may want to consider seeking the guidance of an Arizona attorney. Health care claims can involve state-specific health, insurance, and consumer laws.

I can only identify some general points I hope could be helpful. If you consult with an attorney, I believe they will closely examine this from the standpoint of medical necessity. Can an argument be made that the airlift was medically necessary? A doctor would be your ally there, since laypersons are not ordinarily qualified to make judgments on medical necessity. Maybe the doctor would examine the matter from the standpoint of the medical necessity in arranging immediate medical care for your spouse in a manner not possible with ground transport.

Examine the claim denial or EOB closely. What options does it outline? Arbitration, Civil Court, Appeal, etc?

What timeframe must you act within to challenge the denial? That could be in the order of days. Examine that closely. It is VERY important

An experienced attorney should be able to explore these, and possibly other, issues in greater detail.

I hope your spouse has recovered and regained their health.

Good luck

Justia Ask a Lawyer is a forum for consumers to get answers to basic legal questions. Any information sent through Justia Ask a Lawyer is not secure and is done so on a non-confidential basis only.

The use of this website to ask questions or receive answers does not create an attorney–client relationship between you and Justia, or between you and any attorney who receives your information or responds to your questions, nor is it intended to create such a relationship. Additionally, no responses on this forum constitute legal advice, which must be tailored to the specific circumstances of each case. You should not act upon information provided in Justia Ask a Lawyer without seeking professional counsel from an attorney admitted or authorized to practice in your jurisdiction. Justia assumes no responsibility to any person who relies on information contained on or received through this site and disclaims all liability in respect to such information.

Justia cannot guarantee that the information on this website (including any legal information provided by an attorney through this service) is accurate, complete, or up-to-date. While we intend to make every attempt to keep the information on this site current, the owners of and contributors to this site make no claims, promises or guarantees about the accuracy, completeness or adequacy of the information contained in or linked to from this site.