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Loren
Loren, Attorney
Category: Personal Injury Law
Satisfied Customers: 32040
Experience:  30 years experience in personal injury law.
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Molina Insurance in Silver City, Mexico has denied a

Customer Question

Molina Insurance in Silver City, Mexico has denied a physician assistant's recommendation for my son, age 64, to have an MRI and CAT scan because he has a severe concussion. His symptoms are significant. Mayo Clinic recommends this procedure for diagnosis of the serious nature of a concussion. Is this legal??
If he goes to an Emergency Room at the hospital, can he get treated and then deal w/ the insurance company later. Insurance companies are practicing medicine when they are not qualified to do so.
Submitted: 1 year ago.
Category: Personal Injury Law
Expert:  Loren replied 1 year ago.
Thank you for using JustAnswer. I am Loren, a licensed attorney, and I will do whatever I can to answer your question. I am sorry to hear of your dilemma. I realize how frustrating this is for you and I hope to provide you information which is accurate and useful, even though it may not be the news you were hoping to get.
Your policy should have a section which describes the process you need to follow to appeal a denial for a test or procedure. You need to follow that appeal process.
You can also file a complaint with the state insurance commission.
Finally, if you retain an attorney to write a threatening letter they may cave in to pay for the test rather than risk a bad faith claim lawsuit.
Going to the ER may work, but there is also a risk that the company will say there was no emergency and the visit was an attempt to circumvent their appeal process and you will end up stuck with the bill and have the policy cancelled.
I realize this is probably not the answer you were hoping to receive. Also, please remember that this is not necessarily a moral judgement on my part. As a professional, however, I am sometimes placed in the position of having to deliver news which is not favorable to a customer's legal position, but accurately reflects their position under the law. I hate it, but it happens and I only ask that you not penalize me with a bad or poor rating for having to deliver less than favorable news.
Best regards.
Loren