LOS ANGELES (CNS) – Insurance giant Health Net routinely and illegally denies patients’ claims to important, and sometimes life-saving, medical treatments, according to a lawsuit filed by two patients and the Los Angeles County Medical Association.
The lawsuit, filed Wednesday in Los Angeles County Superior Court, alleges Health Net engages in unfair and unlawful business practices.
The practices “present a continuing threat to the public’s health, safety and welfare,” according to the suit. “Unless Health Net is permanently enjoined and restrained, they will continue to commit acts to cause irreparable harm and injury to the public,” according to the suit.
The complaint alleges that the multibillion-dollar insurance provider refuses legitimate patient claims by employing its own definition and set of criteria for medical necessity, violating well-established standards set forth by state law.
Health Net today released a statement in reaction to the suit.
“Health Net strives in all cases to ensure our members receive the appropriate access to necessary medical care,” the statement said. “Medical care is complex, and sometimes there are differing medical opinions as to what constitutes medically necessary care. In these instances, Health Net carefully follows the guidelines established by the state of California, two regulators, the Department of Managed Health Care and the Department of Insurance.
“These regulatory procedures provide a ready path for members to seek review of Health Net decisions by medical professionals who are not affiliated with Health Net. If the independent, expert reviewer determines that the desired treatment is medically necessary, then Health Net covers it.”
But according to the suit, Health Net is the alleged leader in a corporate practice to avoid paying claims.
“Once again, we see a health insurance company putting profits ahead of patient health and lives,” said Rocky Delgadillo, chief executive officer of LACMA and the former Los Angeles City Attorney. “By deciding which medical treatments are necessary and which ones it will cover, Health Net is dictating medical care from the boardroom. Patient care should be decided by doctors, not business suits.”
Delgadillo said LACMA was part of the suit because it is working to stop health care companies’ practice of preventing doctors from providing medically necessary care and treatment to their patients.