When you are denied health care coverage on bad faith, it is a good reason to contact either an attorney or other parties for help. Being denied health care coverage should not be taken lightly. When you enter a health care agreement, your health care provider is required to abide by the terms of the agreement. No matter how costly your treatment may be, if your health concern is covered by your health insurance agreement, then your health insurer is obligated by law to provide the coverage they agreed upon. 

Health care coverage denial is more common than you may think. When health care companies deny policyholders the right to visit the doctor or the right to a certain treatment, they are going against the terms of a legally binding agreement. What occurs, is that most individuals fail to take legal action. This results in the policyholder digging into his or her pockets to pay for a medical procedure. When a health insurance provider fails to provide the necessary coverage, the only option left for the policyholder is to pay for the cost of the medical treatment themselves. For some individuals this means they must take out a loan, must apply for a second mortgage, or must take on another job in order to pay for the medical bill. In other cases, those with health issues are required to borrow money from their family members which may be a disturbing experience for some. 

To avoid having to borrow money from family members or from a third party, you may consider working with a local agency or attorney to help fight for your rights for coverage. Whenever two parties sign an agreement, the document becomes legally binding. A document such as an insurance document can be upheld in a courtroom. Working with a third party can help the policyholder claim their legal rights to coverage. 

If you have been denied insurance on bad faith, it means your insurance provider is acting against the law and there is no real reason to deny your medical coverage claim. Additionally, it means that you have been denied coverage without a reasonable explanation. If you find yourself with a medical bill that should have been covered by your insurance or you find that you have been denied a treatment based on your insurance's failure to respond to the medical costs, then you have good reason to reach out and ask for help. 

Those living in the United States may contact the Stop Health Insurance Denials at 310-695-5241. When you are confronted with a health insurance denial and you know your health concern is covered by your insurance, you should know that there are ways in which to enforce the terms of your agreement. Additionally, when you have been denied coverage and you know you should be covered, it is a good enough of a reason to reach out and ask for help. Law experts and local agencies can help enforce the terms of your agreement so that you receive the coverage that you rightfully deserve. Every state has their laws regarding health insurance coverage, so it is crucial to work with a local agency or local attorney who understands the laws regarding health insurance in your state. 

How Are Insurance Claims Denied?

An insurance company is just like any other company that seeks to make a profit. Good insurance companies work within fine lines to provide their policyholders with the coverage they require while at the same time finding a way to stay financial fit. However, since companies must turn a profit, it is common for health insurance companies to deny coverage. Before providing coverage, a health insurance company considers a variety of factors that help determine whether coverage is warranted or not. 

In most cases, when coverage is requested, an insurance agent will review the health insurance agreement and will review the policyholders' request. When all checks out, the request is covered by the health insurance company. However, when a request cannot be covered by the health insurance, then a medical director is required to review the case. The medical director will review the account and he or she is obligated to notify the customer of the denial with proper documentation and explanation. A medical director is required to act in good faith and promptly whenever they review a contested request. 

When the director fails to live up to his or her duties, the case may result in a "bad faith" claim. Medical directors are required to live up to certain standards that will be discussed in the next section. 

Elements of Bad Faith

As mentioned earlier, claims are denied commonly, and it is mostly because the health insurance agreement does not cover a certain expense. However, since these issues are related to a person’s health, a medical director is expected to respond promptly to a contested request. In bad faith claims, there are certain factors that stand out including 

  1. The denial of a request without a proper basis 

    Ex: Your insurance covers A, B, and C. However, when you request coverage for B, the insurance company denies your request. Knowing that there is no basis for the denial, the company rejects your request. If your agreement states that you should be covered for B, then your insurer has the obligation to cover your expenses. However, if your insurance policy cannot cover your request, they must provide a reasonable explanation as to why they cannot cover your request. In this case, they would have to explain what can be covered and what cannot be covered as part of your health insurance.

  2. The failure to provide a reason as to why the request is being denied

    Ex: The company denies your health care benefits and does not provide a reason. When an insurance agent denies coverage, there must be enough reason for the coverage denial. If the claim is not approved by the health insurance agent, the case is passed down to the medical director. The medical director has the obligation to respond to a health care coverage denial with a proper explanation. After a thorough investigation, the medical director should respond to the policy holder within fifteen days with a proper explanation about why coverage is being denied. Furthermore, failure to respond to a health care coverage denial can result in a bad faith case. As mentioned above, an insurance company is required to respond to an insurance claim. If the insurance claim is being denied, then the insurance company has the obligation to provide a clear explanation. 

  3. The failure of the administrating body to respond to a claim in a timely manner. 

    Ex: With issues pertaining to health, a response can be the meaning of life or death. Health concerns are sometimes urgent, and they require a timely response. The customer should be notified as soon as possible whether their claim will be covered or not. For if they are not covered, the policyholder will have time to find another way to cover the costs. When the administrative body fails to process the request in a timely manner, it may result in a bad faith case. 

Additional Elements of Bad Faith

The prior factors are commonly discussed in bad faith health care denials; however, it is crucial to understand other factors that may also constitute as bad faith. The following may also be considered examples of bad faith:

  1. Threats to the customer (policyholder): Your insurance company has the obligation to work with their policyholders and deal with their claims. In other words, your insurance representative should work with you without the need for being rude or without the need of using intimidating language. It is seen as bad faith whenever an insurance representative speaks to the policyholder in an aggressive manner. When an insurance company resorts to scare tactics, it is an indicator that they may be breaking the law.

  2. Not providing a clear explanation of the policy: whenever you sign an agreement, the insurance company is required to provide a clear explanation of the coverage you will receive. This will include the amount of a cost that can be covered and the types of injuries or health factors that may be covered by health insurance. When an insurance company fails to explain exactly what will be covered, it may be a bad faith practice. Under the insurance laws in the United States, an insurance company is required to provide a summary of the coverage and benefits. The summary should be written in simple English and should be easy to understand. This includes a glossary that explains the terms that are used in the agreement. It is against the law when a company fails to provide a summary of your coverage plan. 

  3. Not paying the cost the insurance company said it would pay: As explained above, an insurance company is required to let you know exactly what will be covered by the insurance company. This means that if the insurance company claims that it will pay for a certain cost, it will be required to pay for that cost whenever the request is made. For instance, if the insurance company says it will pay up to one thousand dollars on a specific cost, it will be required to pay. If the insurance company pays less the practice may be bad faith. 

  4. Prolonging a response: as with health care denials, the response to a health claim coverage should be made promptly. Health concerns are urgent issues that require an immediate response. The insurance laws in the United States require insurance companies to a health insurance coverage claim within fifteen days. When an insurance company fails to respond to a claim in a proper amount of time the insurance company may be taken to court.

  5. Denying claims without proper investigation: when an insurance company denies coverage, they must provide a clear reason as to why the coverage is being denied. To provide a clear explanation as to why the coverage is being denied the insurance company is required to investigate the claim. When an insurance agent denies your request for coverage, the medical director is required to thoroughly investigate your case. After a thorough investigation, the medical director should provide a reasonable explanation as to why the health coverage is being denied. Without investigating the factors of your case, the insurance company may not have a valid reason for denying your claim.

  6. Offering to cover a small portion of the cost: An insurance agreement will usually dictate how much of a cost it will cover depending on your health concerns. For instance, they may offer to cover full or half of a cost. It is considered bad faith when a health insurance company offers to cover less than they said they would cover given the factors of your case. In some cases, the policyholder may take legal action and claim damages. The damages may include the original cost of the treatment and other expenses.

  7. Not contacting you back: Contacting an insurance company may be your duty in order to get the coverage you need. If you contact an insurance company, they are required to get back to you in a timely manner. However, there are cases when insurance companies fail to contact the policyholder altogether. If your insurance company is playing hard to get, it may be time to get a third party involved. As mentioned earlier an insurance company can be brought into a courtroom whenever they fail to respond to your coverage request. It is seen as bad faith whenever an insurance company fails to get back to their policyholders.

  8. The statute of limitations: When contacting the health insurance company for coverage, the policyholder has a limited amount of time to settle the claim or to file a lawsuit. The time between the injury and the time before it is too late to take action is known as the statute of limitations. It is seen as bad faith when the policyholder files a claim within proper time and yet has his or her claim denied. If you are told you are late on your policy claim, but you know you are well within time, then it may be time to get a third party involved. 

  9. Stalling your case: your case may be stalled whenever an adjuster unnecessarily prolongs negations or asks you to retrieve pointless/unimportant documents. It is seen as bad faith whenever an insurance representative tries to push time so that you reach the statute of limitations. As mentioned above, once you are past the statute of limitations it may be difficult to file a lawsuit and you will not be able to settle a claim with the insurance company. If your insurance agent is requesting unnecessary documents in order to stall your case, then you may need to contact a third party. When it comes to health concerns insurance companies have the obligation to respond to your claims in a timely manner and should not prolong your case.

  10. Another way your case can be stalled is to open a new claim. Your health insurance representative may try to prolong your negotiation period by claiming that your documentation has been lost and therefore he or she will need to reopen the case. It’s a frustrating event whenever you have to go through the insurance claims once let alone twice. If your insurance company claims your documents have been lost and that another claim must be opened, they should ensure that your case is processed as soon as possible. If you find that after opening your case, they are delaying responses or simply not getting back to you when they should, then it may be time to get outside help. 

Find a Bad Faith Insurance Expert Near Me 

If you are living within the United States, you should know that there are a number of laws that protect policyholders. Policyholders have the right to health coverage whenever their claim is within their insurance agreement. When an insurance company fails to provide coverage without a clear explanation, a policyholder may take the case into a courtroom. Like with any other legally binding agreement, a health insurance agreement can be upheld in a courtroom. Once in a courtroom, the policy holder is required to provide proof that the insurance company has acted in a negligent manner.  

When dealing with insurance companies it is encouraged to document every step of the claims process. Ensuring that every conversation occurs through emails or letters will allow your legal representative to have a better understanding of your case. With documented proof, your legal representative will be capable of showing proof that your insurance company has acted in a negligent manner or has acted in bad faith. By law, insurance companies are required to act in good faith meaning that they are required to uphold the provisions of their insurance contract. 

If you are a United States Citizen and you are in search of a health insurance expert, you may contact our bad faith insurance attorney at 310-695-5241. We are ready to evaluate your case and provide the next steps to obtain the coverage that is rightfully yours.