Stop Health Insurance Denial

Common Health Insurance Denial Questions and Answers | Stop Health Insurance Denial

When health insurance companies deny a claim, they usually allege that the test, treatment, or procedure is not covered by the policy or the medical care was not necessary. An insurer will only interpret your policy in a manner that is most favorable to its bottom line. They will interpret the perils your policy covers more narrowly and the exclusions broadly. If you have received a letter denying your benefits, you do not have to accept it and drop your claim entirely. Your attorney can contact the insurance carrier, ask for your payments, and negotiate a fair settlement. If these fail to work, your attorney can help you file a lawsuit against the insurer.

  • Usual and Customary medical expenses

Insurance companies may deny a health claim if they allege that the procedure is not usual and customary. This may create an issue if an insured has already incurred debt but did not receive a notice from the insurer indicating what amounts would be accepted as usual and customary. Before a policyholder can sue the insurer for medical benefits which have been denied as medically unnecessary, one has to take the case through the independent medical review system.

  • Medical necessity

Insurers often deny coverage to the insured in the context of health treatment not being medical reasonable and necessary. But what is considered medically necessary care is often disputed, allowing the insurance company to avoid potential liability because an evaluation of what is medically necessary for one person does not apply to other individuals. Health insurance companies also deny coverage based on a claim that a treatment is investigational or experimental. There are many instances where insurers deny treatment FDA-approved treatment. This is wrongful action because treatment approved by the FDA and is medically necessary for the patient is almost never experimental or investigational.

  • Pre-existing condition

Another one of the common areas of disputes with health insurers is when they claim that the policyholder failed to disclose the existence of an illness or condition contracted before the policy was in force. Under the Patient Protection and Affordable Care Act and in other specific situations, insurers cannot deny treatment by citing pre-existing health conditions. Even so, some insurance policies still deny treatment based on failure to disclose a pre-existing condition. The insurance company is expected to investigate the information provided on the application, including the physician’s records and treatments.

  • Out-of-network treatment

Insurers sometimes deny coverage if the treatment is provided by an out-of-network provider as provided under most Health Maintenance Organizations, Exclusive Provider Organizations, and Preferred Provider Organizations. But if the patient cannot get appropriate treatment within the network, the insurance company has a duty to allow his or her to go for out-of-network treatment. This is even more important for individuals with rare or unusual diseases.

While every case is unique, there are some common reasons cited by insurance carriers when denying long-term disability benefits, including:

  • No objective findings to support a claim

Medical insurance adjusters sometimes deny disability claims, alleging that the claimant never provided adequate objective findings to support their condition. This means that there are no lab results, X-rays, MRIs, hard data, or other medical tests to support the diagnosis. A denial may come your way even if the insurance policy doesn’t provide these grounds as admissible.

  • Job not causing disability

A claims reviewer may deny your claim on the basis that you’re not disabled under the lower standard. Although your job may have stressful, strenuous, or unique requirements, if they do not apply industry-wide, you’re not disabled. You may still be denied coverage even if you have records from your physician stating that you’re unable to work.

  • Failure to fulfill the elimination period

Most long-term disability insurance policies have a requirement that a claimant remains disabled during what is known as an “elimination period,” which typically lasts between 30 days to 6 months. A claim will be denied if the insured does not remain disabled during the entire elimination period. 

Other common reasons for disability insurance denial include:

  • There’s an erroneous definition of your occupation
  • We’ve spoken with your doctor and he or she agrees with us
  • Your records were reviewed by a doctor and he or she says you’re not disabled
  • Your disability is caused by a mental condition
  • Your physical limitations do not prevent you from performing substantial and material duties of your occupation

Typically, an insurance company must investigate the claim and follow applicable laws and regulations to deny coverage. This means making a good faith effort to settle the case within your policy limits, fairly dealing with your case, and disclosing conflicts. If the insurance company refuses to provide coverage for your care, you can appeal or file a lawsuit challenging the denial.  Stop Health Insurance Denial works with policyholders in ensuring that they receive what they need and deserve.

After you’ve received a letter denying your benefits, you must exhaust your “administrative remedies.” This means that before you file a lawsuit, you must first follow the insurer’s internal appeals process. Most health insurance companies give policyholders 60 days from the notice of their decision to file an appeal for benefits, which usually includes submitting a letter explaining why you’re entitled to the benefits and copies of updated medical records. Other insurance carriers will give up to 180 days and will require different documents, so you must carefully look at your denial latter to find out the necessary information you need to support your claim and the amount of time you have to file an appeal. Keep in mind that this is a critical stage of your claim because once the appeals door closes, you’ll only be left with the option of filing a lawsuit. We’ve successfully handled many insurance denial claims and that experience enables us to create very strong appeals that oftentimes result in the reversal of the insurance company’s decision to deny benefits.

Insurance is a complex subject and when your claim has been denied, you need someone who can help you understand your policy and the reasons given by the insurer for denying coverage as well as advocate for you so you get the benefits you deserve. As such, you should always work with a lawyer when dealing with your insurance carrier. Reasons for this include:

  • Insurance adjusters are comprehensively trained on ways to protect their employer’s interests
  • They also take continuing education to keep them up to date on the area of law they deal with
  • One of the main job duties of an adjuster is to find ways to deny the claim or settle the claim for as little money as possible
  • They are trained and equipped with negotiating skills
  • Some of them are compensated depending on how much money they’re able to save for their employer
  • Insurance companies have staff attorneys available to handle their cases around the clock
  • Insurance policies are written in vague and complex language that only a few people would really understand. Sometimes even lawyers and courts disagree and argue over the meaning of various provisions
  • Insurance companies are used to the claim handling process since they deal with such cases every day and have already developed tactics to give them a head start. Compare that to a claimant who does not know what to expect because they have little to no experience

It’s unfortunate that many people are taken advantage of without ever knowing what they should do. But looking at these reasons, you can get a sense when something doesn’t seem right or feel right. Stop Health Insurance Denial attorneys will talk with you at no charge. During the initial consultation, we ask a few questions and can tell you if you need an attorney immediately or not.

With few exceptions, the answer is yes. We understand how difficult it is to deal with an insurer that is refusing to provide your health coverage. An attorney can help you rectify the situation so you get what you deserve. Since we do not charge for an initial consultation, you have nothing to lose by talking to one of our experienced attorneys. So when determining whether your claim is worth getting an attorney involved, there is very little time cost and no financial cost. What’s more, even claims that might involve small payouts can be valuable cases since insurance laws allow goo claims to recover the amount due plus amounts for court costs, attorney fees and other amount based on the circumstances of the case.

Insurance companies are deemed to have superior bargaining power when dealing with claimants and that’s why insurance laws are also favorable to the insured person. This allows punishment for companies that take unfair advantage of its subscribers.

The answer to this question is varied depending on how insurance policies and practices are interpreted by the law of the place you’re filing your claim in. A policyholder’s ability to file a bad faith lawsuit against their insurance company encourages timely and fair payment of claims and provides a remedy should the insurance carrier fail to perform again. But this type of claim isn’t one that a policyholder can consider as a guarantee of getting a recovery. Usually, bad faith litigation is navigated best when prior rulings made by the court are used to create a roadmap. Bad faith actions in general stem from delaying or denying benefits due under a policy or for improper conduct by the insurer.

If benefits that are covered under an insurance policy are wrongfully withheld, then a policyholder may be able to sue for bad faith. But whether the insurer’s action rises to the level of bad faith entirely depends on if they’re unreasonable. But if there is a reason to explain why the benefits are withheld, then there may not be a breach of contract or bad faith. It’s not every matter that will have an issue of bad faith and before such a claim is made, all the facts of each case should be carefully considered. The time limitations by which one can bring an action against an insurance carrier for bad faith varies from one state to the other, so be sure to check that out.

Yes, in some cases. If you’re able to prove that the denial was unreasonable, you might get consequential damages involving money you had to pay out of pocket because of the claim not being honored and extra-contractual damages to compensate for the emotional and mental distress caused by the denial. Punitive damages may also be awarded as a way of convincing the insurance carrier to treat similar claims fairly.

A health insurance company is a business and that means that their first priority is making profits. They will make decisions that are most-effective for them. Sadly, this, in most cases means offering you the lowest possible settlement that they can get away with. This could involve alleging that the medical treatment or procedure was not necessary or was experimental, saying your actions contributed to your ill health or saying that the treatment is not covered under your policy. Whatever reasons they give, it’s important to keep in mind that the amount is just that- an offer. You’re not obligated to accept it. An experienced attorney can negotiate on your for a settlement that is fair and can cover all the medical costs. If they don’t offer a satisfactory amount, then there’s the option of filing a lawsuit against them.

Typically, litigation is necessary to determine if there’s valid coverage for a given claim under the policy. An insurance policy is a contract and the insurance company may get the courts involved to determine whether the insurer is required to honor the contract or not. Sometimes insurance companies initiate lawsuits when they’re unsure of their coverage position and this means that they want the court to decide on the matter. Also, the insurer may sue the policyholder if it does not want to pay a third-party insurance claim. For instance, if your business is often being sued in a liability lawsuit because of accidents and injuries that occur on your premises, your insurer may sue you for a declaration of coverage. This means that you’re being sued by the insurance company and also by the injured person in a different lawsuit.

But just because your insurer initiated litigation over insurance issues does not mean that you don’t have a chance to win. Actually, the opposite may be true. We know the tactics that will get the insurance company to uphold its obligation as required under the policy.

An insurance company is required to handle your claim in a reasonable manner, in a prompt manner, and in good faith. Good faith, in this case, means that the insurance must:

  • Cooperate with you regarding the claim, meaning that they should answer your letters and phone calls in a reasonable amount of time.
  • Investigate your claim thoroughly
  • Attempt to find a basis to pay your claim instead or trying to find reasons to deny it.
  • Pay or deny a claim in a reasonable and timely manner
  • Clearly and thoroughly explain in writing why they are denying a claim or part of the claim
  • Treat you fairly and without bias

As a policyholder, you’re required to:

  • Submit your claim for benefits in a timely manner. If, for instance, you’re filing a claim for a treatment that you’ve already received, your policy will indicate how long after treatment that you must file.
  • Give a statement under oath concerning the claimed medical care
  • Cooperate with the insurance company when the adjusters are conducting their investigations
  • Prove all information all information the insurance company reasonably asks for (if allowed under the policy or the law)

The insurance company will deny your claim if you’ve reneged on your end of the contract or if the claim is not covered by the policy or is fraudulent.

There is no tried and proven formula in determining what a claim is worth. Reasons for this include:

  • A policyholder may not be able to give all the needed information on an initial consultation
  • After the consultation, the attorney has to fully evaluate a case so as to understand the insurance company position, reasons, and evidence to back up their position
  • The policy needs to be read and the language used has to be applied to the circumstances of the claim
  • There may be limitations and exclusion in the policy
  • There may be claims for damages that are not known until after the case has developed

Since there’s no way of fully knowing the value of a case, an attorney will carefully analyze the facts, nature and extent of condition, legal liability, loss future earning, lost income, and medical expenses. But even when all the facts are known, it may still be difficult to determine the potential outcome of a case, especially if it goes in front or a Judge or Jury.

The answer to this question is - it depends. The time it’ll take to settle a claim is based on the facts of the case and the position taken by the insurance company. However, the more complex the case, the longer it may take to settle. Some claims are settled in a short period of negotiations but other cases may take longer. If your claim goes to court, how long it will take before the judge or jury hears your case will be determined by the court’s schedule. Pushing to settle a case too quickly may not yield the results you’re seeking for your recovery. Regardless, the attorneys at Stop Health Insurance Denial will be on your side every step of the way handling your case in an effective, personal, and appropriate manner. When it comes to insurance claims, timing can mean everything and that’s why our firm works hard to distinguish the complexities of a case and develop the best strategy to handle it in the most reasonable period of time. No matter how long a case may take, we’re committed to securing the best possible settlement for our clients.

The answer to this question depends on how the insurance company will respond to negotiations made by your attorney. However, most cases settle before trial and so clients may only have a need for legal representation that does not involve trial work. Regardless, we prepare each thoroughly with the same vigor that we would employ is the case was going to trial. Actually, we are always prepared to go to trial if negotiations don’t bear the results you deserve. Unlike other firms that are willing and unprepared to try cases and thus try to pressure clients to accept lowball settlements, we are always ready to represent the underdog against more powerful foes. Our strategy also helps increase the value of your case because the defending side will take us more seriously.

Many people are hesitant to contact a health insurance claims denial lawyer because they think that they can’t afford an attorney. But you can afford an insurance lawyer to represent you in your case. We usually handle claims on a contingency basis and this means that you do not pay any attorney fees upfront. Also, you pay no attorney’s fees if there’s no recovery. We carefully consider which cases to choose to handle because we pay all the upfront costs for the case, including court fees, expert fees, trial, and the costs of depositions.

Dealing with a health condition, a disability, or the death of your loved one can have a toll on your life and at such a time in your life, legal fees would seem unfathomable. So we’re putting our faith in the legal justice system and your rights to fair compensation. In most cases, individuals who win a lawsuit against an insurance company get their insurance benefits and also receive their attorney’s fees. If that’s not the case, we charge a percentage of the amount recovered and will advance most costs pre-settlement.

Stop Health Insurance has been focusing on practicing health insurance law for decades. Our attorneys will work with top industry experts from independent professionals to engineers and contractors, we retain experts to adequately assess your claim and they can also serve as expert witnesses. The firm fronts all costs so as to build the strongest case for you. The attorneys at our firm are highly experienced, perform with due diligence, and are always prepared to help the insured in obtaining what they’re owed. We offer a complimentary initial consultation where an attorney will listen to the facts of your case and review your claim.

We have helped many clients with their insurance cases in both state and federal levels. We often litigate on issues regarding delays in payment of claims, denial of insurance coverage, underpayment of claims, and bad faith by the insurance companies. We litigate and advise on claims that involve:

  • Health insurance claims
  • Disability insurance claims
  • Errors and Omissions (E&O) insurance claims
  • Life Insurance claims
  • Long-term care insurance claims
  • Wildfire damage and loss insurance claims
  • Rescission of insurance policy

If your question was not included here or the answer given was not detailed enough, do not be discouraged. These are just a few of the most frequently asked questions from our clients. Also, the insurance industry is quite complex and there are too many aspects of the policies and their legal implications. One page is not enough to cover all those.

If you have any further questions or wish to discuss your case with one of our attorneys, please contact our firm today for a free consultation by calling 310-695-5241 or filling in our online contact form. Stop Health Insurance Denial represents policyholders nationwide. We’ve helped many clients in getting their claims approved and recovering health benefits. We want to know your story and help you with your case.

If your claim is denied, we will litigate your case against any health insurer countrywide.

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If your question was not included here or the answer given was not detailed enough, do not be discouraged. These are just a few of the most frequently asked questions from our clients. Also, the insurance industry is quite complex and there are too many aspects of the policies and their legal implications. One page is not enough to cover all those.

If you have any further questions or wish to discuss your case with one of our attorneys, please contact our firm today for a free consultation by calling 310-695-5241 or filling in our online contact form. Stop Health Insurance Denial represents policyholders nationwide. We've helped many clients in getting their claims approved and recovering health benefits. We want to know your story and help you with your case.