What forces the insurance company to give sound rejections? There are numerous categories of care where you would not expect the individual to survive long enough to bring a lawsuit, or the individuals in question would not have the financial means.
Even if a lawsuit is brought, what obliges the insurance company to be reasonable? The ability to deny medication that I am hearing about certainly are not in my insurance contract.
The contract does say things like "standard of care", which is why they need an actual MD to reject a claim. The AI (or whatever) can help but in the end there is a doctor claiming to read the file and say you didn't need whatever it is.
You can bring a suit, and often the threat alone will work. They're counting on you to give up rather than fight. Or be unable to afford it because most lawyers won't take something like that on contingency.
They're content to just reject the bill or refuse to pay.
They'd love it if you sued the doctor for malpractice on the grounds of recommending something that the insurer's doctor rejected.
I don't think you can use the insurer's doctor who rejected your claim. You can try to get their board certification revoked, and in the wake of the murder people are talking about doing that more. But it's not in itself going to get you your meds.
I don’t follow how the insurance companies doctor escapes liability in this case. If they are interfering with a patients treatment plan, doesn’t that qualify as practicing medicine?
Otherwise the insurance company could easily staff itself with less scrupulous poorly qualified doctors and say “your job is to reject claims”. Why would that doctor have any motivation or requirement to fulfill the duties of a “doctor”?
Either the insurers are getting it dangerously wrong, or we've got problems even worse than that.