Rapid legal response overturns insurance decision to reduce critical medical services
SBEMP Attorneys, led by Valerie Powers Smith, Partner and Chair of the firm’s Trust, Estate & Probate and Elder Law & Special Needs Departments, recently secured a critical victory for a client whose son with special needs relies on around-the-clock medical care for his very survival.
The client’s son requires private duty nursing (PDN) care due to severe, life-threatening disabilities that require constant medical supervision. Despite extensive documentation from treating physicians and nursing staff confirming the necessity of this care, the family’s insurance carrier issued a determination to reduce the nursing services.
After receiving the denial letter, the firm promptly prepared and submitted a comprehensive First Level Internal Appeal, supported by more than 150 pages of medical documentation and a detailed response addressing each of the insurer’s stated reasons for the reduction.
The result was swift.
Less than two weeks after the appeal was filed, the insurance carrier reversed its decision and fully reinstated the prior level of medically necessary PDN services.
For the family, the outcome meant more than resolving a legal dispute. It meant preserving the medical support their child depends on every day.