Mansell, Engel & Cole

With adverse publicity potentially on tap, insurer reverses stance

Many readers of our Oklahoma pro-claimants’ insurance law blog perhaps see stories occasionally that spotlight insured parties’ policy wins linked with the intervention of a media source.

That is, an individual who encounters only repeated denials from an insurer suddenly secures claim approval, but only after contacting a reporter or public entity for help.

That spells positive and galling news at the same time, doesn’t it? On the one hand, it’s certainly nice when an individual complying with policy terms is responded to by an insurer performing in the same manner. Conversely, though, an insurer’s good faith is flatly in doubt when it suddenly reverses course only after the potential for adverse publicity.

Enter Aetna here, which is prominently spotlighted in a national media piece chronicling just such an “on the other hand” case. The insurer was contacted by a reporter on behalf of a policyholder it had repeatedly disapproved for treatment. The patient’s suggested surgical procedure was strongly recommended by his doctor. It was also widely endorsed, including by Mayo Clinic experts.

Aetna’s repeated denials over many months came to an abrupt halt following the reporter’s phone call and email. A Los Angeles Times story states that the insurer responded back within a day. It said it was reversing past claim rejections and approving treatment.

Fear of a negative and glaring spotlight can sometimes yield that result.

Here’s something to ponder. Data from California (where the described rejection-then-approval matter took place) stresses that insurers deny more than 25% of all treatment claims they consider. Federal government research indicates that about half of all such claims are reversed when appealed.

That is something to consider for any frustrated policyholder. If claimants can sometimes flip a bad result by allying with, say, a reporter or public advocacy group, how much more often do they prevail when retaining knowledgeable and aggressive insurance law attorneys?

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