Physicians, Insurers Clash Over Medical Necessity in CA

Joe Cantlupe, for HealthLeaders Media , September 27, 2012

While Health Net is the focus of the litigation, LACMA says it aims to end wrongful conduct of "all California health insurers" that prevents doctors from providing proper treatment for patients. Thousands of health insurance claims are routinely denied every year based on insurers' definition of medical necessity that conflicts with California law, according to Delgadillo.

"Health Net is dictating medical care from the boardroom," Delgadillo said in a press statement. "Patient care should be decided by doctors, not business suits."

In a conversation the other day, he elaborated: "We can no longer sit back and wait for other people to solve problems where patients don't have the economic might to solve them, and neither do physicians. But collectively we can. We have to stand up for the rights of patients and that's what physicians have taken an oath to do."

The issue of patient needs for innovative, life-saving procedures is at the heart of the LA case, Delgadillo says.

One of the plaintiffs, Robert Mendoza, 59, was diagnosed with a rare form of prostate cancer, adenocarcinoma with signet ring cells, and his chances of survival were deemed very low. His was one of some 50 cases in the world, Delgadillo says.

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