Q: The orthopedist has recommended surgery, but my health insurance just declined coverage, indicating there is not a sufficient basis for surgery at this time. I am in a lot of pain. How do I get them to make the right decision, and quickly?

-T.H., Wilmington

A: It is important that you have (1) a copy of your relevant medical records, and (2) that you have the written basis for denial  by your health insurer. Review your health insurance policy to determine how to appeal that declination. Here in California, there also is a resource that might be of value to you: the California Department of Managed Health Care (DMHC). You can call the Help Center of the DMHC at 1-888-466-2219 or go to dmhc.ca.gov. 

Make sure your health plan is covered by the Department (many are), but if not you can call the California Department of Insurance Consumer Hotline at 1-800-927-4357.

If your health plan is subject to DMHC oversight, you can ask the department to conduct an Independent Medical Review. This is after you first file a grievance/complaint with your health plan, which is to be dealt with in 30 days. If you are before the DMHC, emphasize the urgency of the situation. If all that fails, hiring a qualified lawyer and taking court action may be advisable.

Q: I am having real problems with Medicare covering items, and believe they are wrong. How can I take on Medicare?

-D.H., Hawthorne

A: Call HICAP (the Health Insurance Counseling and Advocacy Program) at 1-800-434-0222 or go to aging.ca.gov/hicap. Also, Medicare has an appeal process that can apply not just to denial of a treatment, but multiple other items, such as a prescription drug you feel you should be able to obtain, payment of a health care service, and even the amount you are to pay for a health care service. Ask your physician, heath care provider or supplier for any information that may assist you case. Your plan will have paperwork that sets forth how you go about an appeal, and instructions are provided in the decision letter as you move through the process.

The Patient Advocate

The California Office of the Patient Advocate (OPA) is part of the State Health and Human Resources Agency.   OPA provides information about health care quality to assist you in making health care choices. To that end you will find health care quality report cards that show ratings for health plans and medical groups, as well as a health condition rating that compares 16 health plans on different health conditions. For more information, go to opa.ca.gov.

Ron Sokol is a Manhattan Beach attorney with more than 35 years of experience. His column, which appears on Wednesdays, presents a summary of the law and should not be construed as legal advice. Email questions and comments to him at Ronsesq@aol.com or write to him at Ask the Lawyer, Daily Breeze, 21250 Hawthorne Blvd., Suite 170, Torrance, CA 90503.