Q: Is there liability for a insurance company if my condition worsens due to their denial of authorization for more PT?
I was undergoing physical therapy for back/ spine issues with intermittent numbness and improving. Additional authorizations by my insurer were suddenly denied. PT office did not appeal immediately and only did once I received a copy of the letter and informed them. An appeal would take 30 days to be reviewed. My insurer stated since they requested authorization for more visits weekly it was flagged. Instead they should have asked for a larger amount of visits instead of 3/4 at a time. I am in limbo as the office did not immediately appeal as they stated they were gathering documents for the appeal. Then last week my condition worsened to where I have numbness in a new area further down from the existing. I am unable to consult with PT having no visits.
Does the insurer have any liability for my condition worsening due to their denial? They previously wrongly denied a claim and paid after escalation to DOH/DFS.
A: You raise a very good question - and one that does not go overlooked by attorneys in challenging denials of medical care. Unfortunately, it is also a difficult issue to argue in most settings where a claim is closely processed with valid independent medical exams or peer reviews. If you have an attorney on the case, this would be something to discuss with them. Although this is only an individual opinion, in my experience, it can be a difficult theory to pursue. Good luck
A: Addendum - you could reach out to other attorneys to see what their position is. I've only outlined my individual experience on the issue. Good luck
A: Sorry to hear what you've been going through. It is unlikely that your insurance company would be responsible for any physical harm you sustained due to its denial (or delay) in approving additional physical therapy visits. Although you could conceivably claim that the insurance company's denial of additional visits was made in bad faith and in breach of its obligations under your insurance contract, such cases are notoriously difficult to prosecute in New York. Additionally, your damages in any such would arguably be limited to your out-of-pocket costs of having to pay for additional physical therapy visits.
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