Legal responsibility for spouse's medical bills when health insurance is denied
by
Stephen H. Weiner on Feb. 19, 2013
Estate Wills & Probate Lawsuit & Dispute Lawsuit Health Care Health Care Other
Summary: In New York the doctrine of necessaries requires a spouse to pay a spouse's medical bills when insurance coverage is denied. Denial could be based on fine print in the insurance contract. ERISA litigation and negotiation may help.
Legal Responsibility for Our Spouse’s Medical Bills When Health Insurance Coverage is Denied
Am I responsible for my spouse’s medical bills when health insurance coverage is denied?
I recently dealt with a tragic situation that involved legal responsibility for a deceased spouse’s medical bills that a health insurance provider refused to pay. A couple contacted me because the wife was being treated with chemotherapy at one of the most prestigious hospitals, and her health insurance company had refused to pay for chemotherapy. The denial was on the ground that the drug combination used was not “medically necessary” and it was “experimental.” Working with a distinguished oncologist who gave a written opinion on why the therapy was not experimental, we appealed the decision within the company. Nevertheless, the health insurance manager denied the internal appeal. The wife passed away shortly afterwards. After the mourning period the husband advised me that the hospital was billing him for his wife’s chemotherapy for about $80,000, and he had been contacted by a collections law firm. There was no money in the wife’s estate. The collections firm explained that the husband was personally responsible for his spouse’s medical bills based on the “doctrine of necessaries.” This doctrine originally held that the husband is responsible to third parties to pay his wife’s bills for food, shelter, clothing, and medical care. In the 1990s, New York courts made this doctrine apply to both spouses.
How could I help the bereaved husband with his late wife’s medical bill?
I advised the husband that he could file a lawsuit in federal district court against the medical insurance company for wrongful denial of coverage in violation of its insurance contract. The law that applies is called the “ERISA” statute. The legal issue was whether the chemotherapy was “experimental” as that term was defined by the contract. I also advised the husband to let me try to negotiate with the hospital to reduce the bill.
What was the result?
I filed the lawsuit and negotiated with the hospital. The attorneys for the health insurance company settled for a substantial amount. The hospital agreed to take less than the bill. There was money left over from the settlement that I gave to the husband. (Of course there is no guarantee this will happen in every case). This brought him closure and peace of mind.
What can be learned from this situation?
There is “fine print” in health insurance contracts, particularly terms such “medically necessary” and “experimental,” that can be used as an excuse to deny coverage when we are in a highly vulnerable state with major medical bills. If you are in a position to have fewer exceptions for coverage, then demand that at the outset. One cannot take for granted that the insurance company will pay the bill even if a distinguished physician recommends the therapy. If there is a denial of coverage, getting legal advice at an early stage may help. It is important that a qualified physician gives written support for the non-experimental nature of the therapy. Further, there are procedural requirements and time limits that are another way the companies use to avoid payment. Under the ERISA law, all internal appeals of the insurance denial had to be exhausted before a lawsuit could be filed. There was a time limit of one year from the “final” denial of coverage to bring the suit. By meeting these requirements and being prepared, we are able to achieve a good result.
Stephen H. Weiner’s office is at 750 Third Avenue, Ninth Floor, New York, New York 10017. If you have comments or questions about this article he can be contacted at weiner@sweinerlaw.com
Am I responsible for my spouse’s medical bills when health insurance coverage is denied?
I recently dealt with a tragic situation that involved legal responsibility for a deceased spouse’s medical bills that a health insurance provider refused to pay. A couple contacted me because the wife was being treated with chemotherapy at one of the most prestigious hospitals, and her health insurance company had refused to pay for chemotherapy. The denial was on the ground that the drug combination used was not “medically necessary” and it was “experimental.” Working with a distinguished oncologist who gave a written opinion on why the therapy was not experimental, we appealed the decision within the company. Nevertheless, the health insurance manager denied the internal appeal. The wife passed away shortly afterwards. After the mourning period the husband advised me that the hospital was billing him for his wife’s chemotherapy for about $80,000, and he had been contacted by a collections law firm. There was no money in the wife’s estate. The collections firm explained that the husband was personally responsible for his spouse’s medical bills based on the “doctrine of necessaries.” This doctrine originally held that the husband is responsible to third parties to pay his wife’s bills for food, shelter, clothing, and medical care. In the 1990s, New York courts made this doctrine apply to both spouses.
How could I help the bereaved husband with his late wife’s medical bill?
I advised the husband that he could file a lawsuit in federal district court against the medical insurance company for wrongful denial of coverage in violation of its insurance contract. The law that applies is called the “ERISA” statute. The legal issue was whether the chemotherapy was “experimental” as that term was defined by the contract. I also advised the husband to let me try to negotiate with the hospital to reduce the bill.
What was the result?
I filed the lawsuit and negotiated with the hospital. The attorneys for the health insurance company settled for a substantial amount. The hospital agreed to take less than the bill. There was money left over from the settlement that I gave to the husband. (Of course there is no guarantee this will happen in every case). This brought him closure and peace of mind.
What can be learned from this situation?
There is “fine print” in health insurance contracts, particularly terms such “medically necessary” and “experimental,” that can be used as an excuse to deny coverage when we are in a highly vulnerable state with major medical bills. If you are in a position to have fewer exceptions for coverage, then demand that at the outset. One cannot take for granted that the insurance company will pay the bill even if a distinguished physician recommends the therapy. If there is a denial of coverage, getting legal advice at an early stage may help. It is important that a qualified physician gives written support for the non-experimental nature of the therapy. Further, there are procedural requirements and time limits that are another way the companies use to avoid payment. Under the ERISA law, all internal appeals of the insurance denial had to be exhausted before a lawsuit could be filed. There was a time limit of one year from the “final” denial of coverage to bring the suit. By meeting these requirements and being prepared, we are able to achieve a good result.
Stephen H. Weiner’s office is at 750 Third Avenue, Ninth Floor, New York, New York 10017. If you have comments or questions about this article he can be contacted at weiner@sweinerlaw.com