Health Net illegally denied doc-ordered care, lawsuit says

Health Net has illegally denied patients' medical treatments even though they've been ordered by physicians, according to a lawsuit from the Los Angeles County Medical Association (LACMA) and two patients.

Although California law allows health insurers to deny coverage of treatments considered unreasonable or contrary to medical standards, the lawsuit, which was filed Wednesday in Los Angeles County Superior Court, claims Health Net violated the law by refusing to pay for two patients' treatments.

The patients, Robert Mendoza and Kalana Penner, were both denied physician-ordered surgeries. In Mendoza's case, his doctor recommended a $30,000 surgery to help treat an aggressive and rare form of prostate cancer. But Health Net wouldn't cover the operation because it wasn't medically necessary, the Los Angeles Times reported.  

Penner suffered from a nerve condition that caused chronic back, neck and head pain for 10 years. Her neurosurgeon recommended she undergo "occipital nerve stimulation." Although Health Net initially denied her claim, an independent medical review overturned that decision and the California Department of Insurance ordered the insurer to pay for the procedures, Reuters reported.

"Once again, we see a health insurance company putting profits ahead of patient health and lives," LACMA CEO Rocky Delgadillo said in a statement. "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," he said.

Health Net wouldn't comment on the lawsuit, but told the LA Times  "it strives in all cases to ensure our members receive the appropriate access to necessary medical care. Medical care is complex, and sometimes there are differing medical opinions as to what constitutes medically necessary care."

To learn more:
- read the LACMA lawsuit (.pdf) and statement
- see the Los Angeles Times article
- check out the Reuters article

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