Don’t take our word for it. Take the records.

A 17-year-old was denied coverage for the liver transplant her doctors said she needed to live; the insurer called it experimental. After public pressure the denial was reversed, and she died within hours of the approval. The insurer's own communications chief, Wendell Potter, resigned months later, apologized to her family on national television, and became the industry's best-known whistleblower.

The approval came. It came hours too late.

Sources: case timeline · ABC News on Potter · NBC

A college student's severe ulcerative colitis was finally controlled by a Mayo Clinic treatment plan. His insurer flagged him as a "high dollar account" and reviewed how to stop paying. When his family sued, the case file included recorded calls of employees laughing after a denial and math on what pushing him back to failed treatments would save.

The denial was recorded. So was the laughter.

Sources: ProPublica · HealthLeaders

A 61-year-old with heart failure needed the heart catheterization his cardiologist ordered. The insurer's denial contractor rejected it twice and approved only a cheaper stress test. He died of cardiac arrest about 36 hours after that test. His doctor's chart read: "ideally he needs LHC (denied twice by insurance)."

Insiders described the contractor's adjustable algorithm, nicknamed "the dial," that could be tuned to raise denial rates.

His doctor's chart read: "ideally he needs LHC (denied twice by insurance)."

Sources: ProPublica · CNN

A 50-year-old Michigan father with aggressive lymphoma was denied the CAR-T therapy his doctors said was his last option; his insurer classified it as gene therapy rather than cancer treatment, even as other payers covered it. He died still fighting the denial. A former medical officer of the insurer later said the decision was about cost.

The reporting led Michigan regulators to require coverage of proven cancer treatments.

He died still fighting the denial.

Sources: ProPublica · follow-up

A 91-year-old broke his leg and ankle and entered rehab. His plan cut off coverage after about two and a half weeks against his physicians' advice, guided by an algorithm that predicted how long his recovery should take. His family paid up to $14,000 a month out of pocket until he died (source: STAT investigation and class action filings).

When patients appealed denials like his, a federal watchdog found insurers reversed themselves 97 percent of the time (source: OIG via STAT). The system counts on people not appealing.

The system counts on people not appealing.

Sources: STAT · Healthcare Dive

A physician himself, he had a $350 blood test denied as not medically necessary (source: ProPublica). He appealed for seven months and won. His case exposed a bulk-review system where insurance company doctors rejected 300,000 claims in two months without opening patient files (source: ProPublica; the insurer disputes the characterization).

One reviewing doctor denied roughly 60,000 claims in a single month (source: ProPublica). A former insider: "We literally click and submit."

"We literally click and submit."

Sources: ProPublica · CBS

A 36-year-old bought the most popular marketplace plan partly for its long list of in-network mental health providers. The listings were largely phantom: after 21 documented calls to the insurer, he had not received a single therapy session. He was found dead in his apartment in May 2023, and his mother's lawsuit says the directory was false.

21 calls. Zero appointments. On a plan sold for its mental health network.

Sources: ProPublica · NPR affiliate

A young Virginia woman with small fiber neuropathy was recommended infusion therapy by specialists at two university health systems. Her insurer denied it repeatedly while she lived in chronic pain, and its own patient advocate suggested she try drugmaker charity programs instead of coverage.

"I'm paying a lot of money for health insurance. I don't understand why they won't help me."

Source: KFF Health News

A 27-year-old had cochlear implant surgery with the insurer's written preapproval in hand and her deductible met. She was then billed $139,362.74 and spent months fighting six-figure notices (source: KFF Health News Bill of the Month).

Preapproved in writing. Billed anyway.

Sources: KFF · NPR

Her insurer preapproved diagnostic tests at the Mayo Clinic, then retroactively denied payment as not medically necessary after the tests were done, leaving her more than $34,000 in bills (source: KFF Health News). On disability income, she went bankrupt and lost her home.

The approval letter came before the care. The denial came after.

Source: KFF Health News

A Texas high school teacher was rushed to the nearest ER during a heart attack. The out-of-network hospital balance-billed him $108,951 after his plan paid nearly $56,000 (source: NPR/KHN Bill of the Month). Days after the story aired, the bill fell to $332.29.

$108,951 on Monday. $332.29 by Thursday. The only thing that changed was a news story. (Pre-No Surprises Act.)

Sources: NPR · KHN

A baby bumped his head, was checked at a San Francisco ER, napped in his mother's arms, drank formula, and went home in under three and a half hours. The bill was $18,836, driven by a $15,666 trauma-activation fee (source: Vox ER billing investigation). The reporting revealed the city's main trauma center was out of network with every private insurer.

After the story, the hospital ended balance billing and capped ER bills. (Pre-No Surprises Act.)

The bill was $18,836, driven by a $15,666 trauma-activation fee.

Source: Vox

A 3-month-old recovering from open-heart surgery went into respiratory distress, and his doctors ordered an emergency air transfer. The insurer denied the flight as not medically necessary, second-guessing the treating physicians after the fact, and the family owed $97,599 (source: KFF/NPR Bill of the Month).

A desk review overruled the doctors standing next to the baby.

Source: KFF Health News

A rural Tennessee woman was airlifted after a catastrophic brain bleed and later died. Because of a coverage gap the No Surprises Act doesn't reach, the air ambulance company billed her estate $81,739.40 for the single flight (source: NPR/KFF Bill of the Month).

The bill outlived the patient.

Sources: NPR · KFF

Diagnosed with leukemia while traveling, he was flown home to North Carolina to continue treatment. His insurer called the flight not medically necessary and initially paid about $72,000 against a $489,000 charge, leaving the family exposed for the rest (source: KFF/NPR Bill of the Month).

Roughly 15 cents on the dollar, for a cancer patient's flight home.

Sources: KFF · NPR

He vetted his in-network surgeon and in-network hospital for neck surgery. An out-of-network assistant surgeon he never recalled meeting then billed $117,000, nearly 19 times the primary surgeon's fee (source: The New York Times). The case made "drive-by doctoring" a national term.

The insurer paid the $117,000 nearly in full rather than fight, which is why the scheme worked. (Pre-No Surprises Act.)

The case made "drive-by doctoring" a national term.

Source: The New York Times

In a sworn deposition, an insurance company medical director admitted he never once looked at a patient's medical records while deciding denials over three years, and said that was company protocol. The case began when a college student with an immune disorder was denied his infusion therapy. California's insurance commissioner opened an investigation; the suit settled.

Under oath: three years of denials, zero patient records read.

Sources: CNN · Forbes

A pediatrician reviewing claims for an insurer says she was pressured to clear cases faster than she could responsibly read them, while colleagues who rubber-stamped denials hit their numbers. She says she was threatened with termination for being too slow, meaning too thorough.

Punished for reading the file before deciding a patient's care.

Source: ProPublica

In the AMA's national survey of 1,000 physicians, 94 percent said prior authorization delays necessary care and 78 percent said patients abandon treatment because of it (source: AMA prior authorization survey). Practices handle about 39 prior-auth requests per physician every week.

About 1 in 4 physicians report prior authorization led to a serious adverse event for a patient in their care, including hospitalization, permanent impairment, or death (source: AMA survey).

About 1 in 4 physicians report prior authorization led to a serious adverse event.

Source: AMA survey PDF

KFF Health News profiled primary care physicians leaving insurance-based practice: one left after being required to see 22 to 28 patients a day in 11-minute slots; another converted to a membership practice because "I always felt I was cutting my patients off"; a third retired early.

11-minute appointments as the price of staying in the system. This is the burnout Vxtra's co-founder describes from the inside.

11-minute appointments as the price of staying in the system.

Source: KFF Health News

A Michigan manufacturer discovered its plan administrator had inflated hospital claims with hidden surcharges for roughly 20 years, marking up employee claims by as much as 22 percent and keeping the difference (source: Sixth Circuit opinion). Federal courts ruled it a fiduciary breach and upheld a $6.1 million judgment.

In the litigation it emerged that 83 percent of the administrator's self-insured clients had no idea the fees existed (source: case summaries). More than 35 similar employer suits followed.

83 percent of the administrator's self-insured clients had no idea the fees existed.

Sources: Sixth Circuit opinion · National Law Review

A Michigan boat builder alleges its plan administrator ran software "flip logic" that systematically overpaid claims with the employer's money, then charged the employer a share of the savings for clawing back the very overpayments it created (allegations; source: Sixth Circuit opinion reviving the case). The appeals court held the administrator plausibly acted as a fiduciary profiting from its own mismanagement.

Paid once to create the overpayment, paid again to recover it, per the complaint.

Sources: Sixth Circuit opinion · case analysis

One of America's largest food companies alleged its plan administrator kept undisclosed fees and paid improper claims with plan money across more than $1 billion in claims (allegations; source: filed complaint). When the company asked for its own claims data, it says it received 178 cherry-picked claims.

A billion-dollar plan, and the sponsor couldn't see its own numbers.

Sources: complaint · Healthcare Dive

A Florida school district paying its benefits consultant under $200,000 a year alleged the consultant collected roughly $4 million in undisclosed commissions from the very carriers it was hired to scrutinize (allegations; source: Florida Politics and Business Insurance coverage). The case settled for $582,000 with no admission of wrongdoing.

The question the district couldn't answer until it sued: whose advisor was he?

Sources: Florida Politics · Business Insurance

Two Connecticut union health funds spent months asking for their own claims data, which federal law entitles them to review. The complaint alleges the network stonewalled behind gag clauses that the Consolidated Appropriations Act had already banned, to conceal how claims were repriced (allegations; source: filed complaint, D. Conn.).

The data the law says is yours, kept behind a clause the law had already outlawed, per the complaint.

Sources: complaint · docket

An employee sued her own employer's plan fiduciaries, alleging they let the plan's drug middleman charge $10,239.69 for a 90-day generic supply that retail pharmacies sell for as little as $40.55 (allegations; source: filed complaint). The first complaint was dismissed on standing, and the case sparked a wave of similar suits, putting every plan sponsor on notice.

The lawsuit's target wasn't the middleman. It was the employer who never checked.

Sources: complaint · case analysis