What Are the Most Common Disputes With Health Insurance Claims?
If your claim for health insurance benefits has been wrongly denied, or if you are disputing some other action taken by your health insurance company, a California health insurance claims attorney such as McKennon Law Group PC may be able to help.
When you purchase health insurance, privately or through your employer, you trust that your medical expenses – except for co-payments and deductibles – will be paid by the insurance company.
But what can you do if a claim submitted to your health insurance provider is rejected or if the insurance company offers you an amount that is far below what the claim is actually worth? We discuss this below. But first, what are the most common types of denials by health insurers? They are:
- denied payment for care already provided based upon an exclusion in the policy;
- your care was not medically necessary or required;
- you are ineligible for the benefit;
- your treatment is “experimental;”
- you have a pre-existing condition;
- another insurer is primarily liable to pay for the medical procedure; and
- prior consent for the treatment was not obtained.
What Can Happen If Your Health Insurance Claim Is Denied?
If your claim is denied or if the insurance company offers to pay a lesser amount than what the claim is worth, you may be responsible for paying these medical expenses out-of-pocket. This could mean serious financial hardship – even bankruptcy – for far too many people.
Disputes between policyholders and health insurance providers are becoming more frequent. Disagreements may arise over a denial of coverage for services already provided, a refusal to approve a procedure or a visit to a specialist, or an incorrect charge for services or office visits.
It is important to know exactly what steps to take when you dispute a charge or disagree with a decision made by your health insurance provider. If you continue reading, you will learn what steps to take should this happen to you, and you will also learn more about your rights as a health insurance policyholder.
What Should You Do When Faced With a Health Insurance Dispute ?
The first step you should take is to make certain that you know what your health insurance policy covers and does not cover. You should make sure that you fully understand what procedures you must follow in order to comply with your policy and retain your coverage.
If you are familiar with your policy’s details, you will know if your health insurance complaint will be considered legitimate, and if it is, you will be able to point to the policy language that demonstrates that you are right and the insurance company is wrong.
To dispute a charge or a coverage decision, you may want to start by contacting the claims representative who denied the claim or the insurance company’s customer service department. You may even ask for intervention by a company supervisor. The company may simply have made a mistake. Insurance company personnel may be able to reverse mistaken charges or approve services that were initially denied.
If you cannot obtain reversal of its decision, ask the insurer for a precise written explanation of the reasons why the claimed services were not authorized or why the coverage was denied.
If your denied health insurance claim cannot be resolved by working with the insurer informally, then it is time to contact a California health insurance claims lawyer such as the McKennon Law Group PC. The attorneys at McKennon Law Group PC can help you by appealing the insurance company’s decision to deny your insurance claim. We can also file litigation to request a court to reverse the insurer’s decision.
When May You Appeal Directly to the Insurance Company?
Federal law establishes the following deadlines for insurance companies to review and decide formal appeals:
- sixty days for denials of services that have already been provided
- thirty days for denials of nonurgent care that has not yet been provided
- seventy-two hours for denials of urgent care services
What Steps Can You Take If Your Appeal Is Denied?
If your appeal is denied, you are entitled to a full explanation, and you have the right to take legal action. If the company made a mistake or violated the terms of your policy, a California health insurance claims attorney such as McKennon Law Group PC can fight for your rights and help you recover your wrongly denied insurance benefits.
If your policy was obtained through a private employer, it is likely governed by the Employee Retirement Income Security Act of 1974 (ERISA). Under ERISA’s restrictions, you may sue only for the policy benefits, attorneys’ fees, and interest on past-due benefits.
If your policy is not governed by ERISA, and if your health insurance company was operating in “bad faith” when it rejected your claim, you may sue for the policy benefits, the “consequential damages” caused by the insurance company’s bad faith conduct, punitive damages, attorneys’ fees, emotional distress, and interest on past-due benefits.
How Will an Insurance Claims Lawyer Help You?
Do not accept an offer from the insurance company for an amount that does not compensate you fully, fairly, and reasonably. When you have reached the point that you should no longer deal with the insurance company on your own, it is best to have a California health insurance claims lawyer such as McKennon Law Group PC working for you from the moment you learn your claim has been denied and informal attempts at resolution do not work. Your claims lawyer can help you appeal directly to the insurance company, negotiate with the company on your behalf, and if necessary, file a lawsuit against the insurance company.
You may be tempted to take a quick offer from the insurance company, especially if you cannot yet return to work and you need money, but settling for less than your claim is worth also means that you will be ineligible to take further legal action or seek additional compensation for your claims.
It Costs Nothing to Begin the Legal Process with McKennon Law Group PC
We will review your claim during a no-cost, no-obligation first legal consultation. As your insurance claims attorneys, you pay us nothing unless and until we recover health insurance benefits on your behalf.
Every health insurance dispute is unique. Take advantage of that free first legal consultation to receive the personalized legal advice you need and to learn how the law applies to your own circumstances.
The important thing to remember is that you should not let the insurance company have the last word regarding your health insurance claim. If you cannot resolve your dispute informally and your case goes to court, a court of law will have the last word.
It is imperative that you are represented by an insurance claims attorney who will effectively and aggressively fight on your behalf, who knows what it takes to prevail, and who will bring the case to its best possible outcome. You should contact us as soon as possible.