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?
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
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