[lumost]

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.

[jfengel]

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.

[lumost]

Can I sue the insurance companies doctor for malpractice? In standard care the doctor is liable, not the hospital.

[jfengel]

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.

[lumost]

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”?

[jfengel]

It pays pretty well and you don't have to see any patients. And as they say, do you know what they call the one who graduates last in med school? "Doctor"

The problem with suing the doctor is that you need a fairly high standard of evidence to prove malpractice. If they have any way to say "this is not utterly unreasonable", they can claim it was your doctor's opinion versus theirs.

And the insurance company has many lawyers looking for ways to let them say that. It's why they have AI rather than just rejecting claims at random.

Though it appears they often do that as well. But the burden is still on you to prove it.