Waiting for health insurance approval can be frustrating. But when the care being delayed involves cancer treatment, surgery, diagnostic imaging, cardiac care, neurological symptoms, or another serious medical condition, the consequences may go far beyond inconvenience.
Patients sometimes find themselves caught between their doctor, hospital, and insurance company. A physician recommends an MRI, CT scan, surgery, medication, or specialist consultation, but the insurance company requires prior authorization or determines that the treatment is “not medically necessary.”
Days turn into weeks. Symptoms get worse. A condition that might have been treated earlier becomes more difficult to manage.
When that happens, patients often ask:
Can an insurance delay lead to a medical malpractice lawsuit?
The answer depends on what happened, who was responsible for the delay, what the medical providers did in response, and whether receiving appropriate care sooner probably would have changed the patient’s outcome.
A delay in treatment does not automatically mean medical malpractice occurred.
In a New York medical malpractice case, the central questions generally include whether a doctor, hospital, or other medical provider failed to meet accepted standards of medical care and whether that failure contributed to the patient’s injuries.
When insurance is involved, the situation can become more complicated.
An insurance company may deny authorization, but a medical provider may still have responsibilities when a patient faces a serious or rapidly worsening condition.
Depending on the circumstances, questions may include:
The fact that an insurance company refused to approve treatment does not necessarily answer whether the medical care itself was appropriate.
Prior authorization requires a health care provider to obtain approval from an insurance company before certain treatments, medications, tests, or procedures will be covered.
Common services requiring authorization may include:
For many routine medical situations, a short authorization process may not affect the eventual outcome.
For other conditions, however, time matters.
Consider a patient experiencing worsening neurological symptoms whose doctor believes an MRI is needed to evaluate possible spinal cord compression. If the scan is repeatedly delayed and the patient’s neurological condition deteriorates, an investigation may need to determine whether everyone involved responded appropriately to the increasing urgency.
Similar concerns can arise with suspected cancer, cardiovascular disease, progressive infections, vascular conditions, and other illnesses where delays can affect treatment options or outcomes.
New Yorkers whose insurers deny care as medically unnecessary, experimental or investigational, or under certain out-of-network circumstances may have appeal rights through the New York State Department of Financial Services.
In situations where waiting for the normal appeal process could seriously jeopardize a patient’s health, New York also provides procedures for certain expedited external appeals.
One of the most common insurance problems patients encounter is a denial of diagnostic imaging.
A doctor may order an MRI or CT scan because symptoms suggest a condition that cannot be adequately evaluated through a basic physical examination or X-ray.
An insurer may nevertheless deny the test or request additional medical documentation before approving it.
If your MRI, CT scan, or another diagnostic test is denied, consider taking several steps.
Request the denial in writing.
The reason may involve medical necessity, missing documentation, failure to complete another test first, an out-of-network provider, or an administrative issue.
Ask whether the medical office plans to appeal the decision or submit additional documentation.
Your physician may be able to explain why the test is medically necessary or request an expedited review if your condition is urgent.
Do not assume you simply have to wait for an insurance company if your condition is deteriorating.
Tell your medical provider when symptoms change or become more severe.
Insurance authorization should not prevent someone experiencing a medical emergency from seeking emergency evaluation.
Federal protections under the Emergency Medical Treatment and Labor Act, commonly known as EMTALA, generally require covered hospital emergency departments to provide an appropriate medical screening examination and stabilizing treatment for an emergency medical condition regardless of insurance status.
In these situations, a patient advocate may be necessary to assist you in obtaining the care you need.
Diagnostic delays can become especially serious when imaging would have revealed a time-sensitive condition.
Potential examples may include:
Cancer: Imaging may help detect a tumor, determine its stage, or identify whether disease has spread.
Stroke or neurological disease: Brain imaging may be critical when physicians are evaluating certain neurological emergencies.
Spinal cord compression: A delay in diagnosing compression of the spinal cord may allow neurological injury to progress.
Internal bleeding: CT imaging can sometimes be an important part of evaluating trauma or internal injury.
Vascular conditions: Certain imaging may be necessary to identify dangerous problems involving blood vessels.
The key legal question is not simply whether an insurance company denied the scan.
A medical malpractice investigation may ask whether the health care providers appropriately recognized the urgency of the patient’s condition and responded to the denial in a way that was consistent with accepted medical practice.
Insurance companies frequently use the phrase “not medically necessary” when denying treatment.
That does not necessarily mean your doctor agrees.
It generally means the insurer has determined, based on the plan’s criteria and the information submitted, that it does not believe the requested treatment meets its coverage requirements.
Patients should carefully review the denial notice.
In New York, patients may generally appeal qualifying denials involving medical necessity through their health plan and, in appropriate cases, seek an independent external review.
The New York State Department of Financial Services explains health insurance consumer rights, including utilization review and external appeal procedures.
For some external appeals, New York requires the application to be submitted within a specific deadline following the health plan’s final adverse determination, so patients should not ignore a denial letter or put off investigating their appeal rights.
Cancer is one area where treatment delays deserve particular scrutiny.
Depending on the type and stage of cancer, delays may affect whether a tumor grows, spreads, becomes more difficult to remove, or requires more aggressive treatment.
Research examining several major cancers has found an association between treatment delays and worse outcomes. A large systematic review involving more than one million patients found that treatment delays were associated with increased mortality across numerous cancer treatment settings.
That does not mean every delay in cancer care constitutes malpractice.
Cancer cases are highly individualized. Some tumors are aggressive and require rapid treatment, while others may safely be monitored or treated on a different timetable.
A legal and medical investigation may examine:
These issues often require detailed review of medical records, imaging, pathology, insurance correspondence, and expert medical opinions.
This is often the hardest question and every case will vary.
Sometimes the insurance company causes the initial delay.
In other situations, a doctor’s office may fail to submit the necessary paperwork, respond to an insurer’s request, appeal a denial, or communicate the urgency of a patient’s condition.
Hospitals and medical systems can also have authorization departments and internal procedures that affect when treatment occurs.
More than one organization may therefore be involved in the timeline.
Determining responsibility requires reconstructing exactly what happened.
Useful evidence may include:
Patients should consider keeping copies of insurance correspondence and communications with medical providers when a significant treatment dispute occurs.
If you are currently facing a delay, the immediate priority should be your health rather than a potential lawsuit.
Ask your physician how urgent the recommended treatment is and what symptoms should cause you to seek emergency care.
You can also:
Possibly, but an insurance delay alone does not automatically create a medical malpractice claim. An investigation must determine who was responsible for the delay, whether appropriate steps were taken to obtain timely treatment, and whether the delay caused additional harm.
A doctor is not necessarily responsible for an insurer’s decision, but questions may arise about how the physician responded to the denial, particularly when the patient’s condition was urgent or worsening.
The timing should be investigated. Relevant questions include why the MRI was requested, why it was denied, whether the physician appealed, how long diagnosis was delayed, and whether earlier diagnosis would probably have changed the patient’s treatment or outcome.
Not always. Some surgeries can appropriately be postponed. A potential delay-in-treatment malpractice case typically requires evidence that medical providers failed to act appropriately and that the delay caused or increased the patient’s injuries.
New York provides internal and, in qualifying circumstances, external appeal procedures for certain medical-necessity denials. Expedited review may also be available when waiting could seriously threaten a patient’s health.
Cancer progression during an insurance-related delay may warrant a detailed review of the medical and insurance records. Whether there is a viable claim depends on the type of cancer, length and reason for the delay, actions taken by medical providers, and whether earlier treatment probably would have produced a better outcome.
When an insurance delay stands between a patient and necessary medical treatment, determining responsibility can be complicated.
At Salenger, Sack, Kimmel & Bavaro, LLP, our attorneys investigate medical malpractice claims involving delayed diagnosis, delayed treatment, surgical care, cancer, neurological injuries, and other serious medical conditions throughout New York.
If a surgery, diagnostic test, specialist consultation, or other treatment was delayed and your condition became significantly worse, our attorneys can review the circumstances surrounding your medical care and determine whether the delay may support a medical malpractice claim.
Contact SSKB Law to discuss your potential case with a New York medical malpractice attorney.
This article is provided for general informational purposes and does not constitute legal or medical advice. Every case depends on its individual facts.