When you take out health insurance coverage and stay on top of all your premiums, you have the right to expect that your insurance company will act in good faith and treat you fairly by paying out any valid claims you may have. However, if your insurer fails to do so, do not take the rejection lying down since there are legal options available that can hold them accountable for their bad faith actions.
Since insurance companies have teams of lawyers on retainer that work round the clock, you need the services of a qualified insurance claim denial lawyer to help you fight back. A Stop Health Insurance Denial lawyer will look at all aspects of your case to determine whether the denial was legitimate, look for any mistakes in the paperwork that could fast-track an internal appeal and maybe have your claim accepted, or file an appeal with a court of law if all internal avenues have been exhausted.
Life Insurance Law Protects You and Your Beneficiaries
Life insurance law has numerous provisions that govern the actions of insurance companies. Some portions of the statutes have placed restrictions on life insurance companies such as; the insurer cannot deny paying benefits just because the insured (you or your loved one) committed suicide unless the act took place within a year of purchasing the policy.
Delay of Life Insurance Benefits
Other provisions of life insurance law place affirmative obligations on your insurance carrier. One such important provision requires your insurer to complete their investigation into your claim within 30 days. However, this 30-day period starts from the date the insurer receives notice of your claim and not upon the issuance of a death certificate or death of the insured.
While there is an exception for situations whereby the insurer cannot reasonably complete their investigation within 30 days, the company cannot simply decide to add more time. If it happens that the investigation has not been completed within 30 days and the insurer is not ready to deny or approve your claim, written notice is required.
The notice must include the insurance company’s explanation as to why it could not complete the investigation in a timely manner. Your lawyer will use this written document to determine whether the company unreasonably delayed the claim. If this was the case, your lawyer could get the insurer to pay you interest on the funds withheld during the investigation period.
The truth is that this tactic stonewalls many beneficiaries that some insurers use to delay claims. Instead, they chose to wait patiently as they receive letter after letter justifying the delay. Some do not even hear back from the insurance company at all. This is a major reason why you need an insurance denial lawyer to help fast-track claims.
Denial of Health Insurance Claims and Benefits
There are several reasons why insurance claims are denied or rejected by health insurance companies. A rejected claim translates to a major financial loss to you since you have to dig into your pocket to pay all medical expenses incurred. Insurers often cite exclusions (reasons) that you may not know about or use loopholes to get out of paying certain claims.
Ergo, it is important to read the fine print when taking out insurance cover and also know about potential exclusions and loopholes used by insurers to avoid paying claims. This will enable you to remain on top of all claims, submit your paperwork on time, collect and keep all relevant records, and prepare for denials by having all your evidence on hand.
Health insurers use several exclusions in their insurance offerings to prevent clients from taking undue advantage of these essential services. As such, claims can typically be legitimately rejected according to the terms and conditions set in your policy papers. Some common exclusions that can cause your claim to be denied include:
- Pre-Existing Illnesses
Almost all health insurance companies have this exclusion in their policies. It means that your insurer will not cover any disease that has already been diagnosed or detected before the date of taking out your policy. Generally, these pre-existing conditions are not covered in your policy in the first few years (usually three or four depending on your insurer). For example, if you are suffering from high blood pressure when taking out your policy, then any medical expenses that arise due to that specific condition will not be covered for a set period.
This policy is in place to protect insurance companies by preventing people from rushing to take out insurance covers after a diagnosis and before they begin treatment. Otherwise, insurers would lose a lot of money in claims. However, many insurers provide cover for pre-existing conditions under their group health insurance plan.
- Waiting Period
Health Insurance companies do not provide cover for any sort of treatment within a set period of time – usually between 30 and 90 days from the date of issue. The waiting period differs from one provider to another and the medical condition in question. Moreover, there is a longer waiting period for certain disease and treatments such as internal tumors, cysts, and surgery on sinuses and tonsils. There is no waiting period set for any medical expenses incurred due to an accident.
Most health insurance companies have waiting periods for a selected list of diseases that are not covered until the lapse of a set period, usually 2 to 4 years. For example, if you took out a policy in 2019, the said selected diseases will only be covered from 2021 and beyond. If you are hospitalized for any of the stated illness during the waiting period, your claim will be denied.
Some of the diseases that are usually subject to set waiting periods include: ENT surgeries and disorders, kidney stones, arthritis, cataracts, skin tumors, cysts, spinal disorders, dilation and curettage, deviation and sinusitis, gall bladder stones, osteoporosis, and joint hip replacement surgery among others.
- Permanent Exceptions
All health insurance policies have a list of diseases that are never covered at all times. Some of the common diseases that fall under this category include dental treatments, cosmetic surgeries, infertility, hormone replacement therapies, birth control procedures, as well as Aids and other HIV-related diseases. The reason for these permanent exceptions is that most of these diseases are not considered genuine medical conditions whose treatment is necessary but rather cosmetic surgeries.
- Medical Necessity
Insurance policies generally only cover medically necessary procedures that are required for your health and recovery. Therefore, procedures and treatments that are not considered medically necessary by a medical professional are not covered by the insurer. One such example is plastic surgery.
Some life insurance companies may use the above exclusions to explain away their denial to approve a legitimate claim. In such cases, the insurer uses tons of paperwork and technical terminology to explain their reasons for denying the claim, which a layman may not understand. However, your lawyer can easily go through the explanation to determine the validity of the denial.
Other Possible Reasons for Claims Denial
- Material Misstatement
Material misstatement accounts for a majority of life insurance disputes across the United States. It refers to a situation where an insured individual lies about something significant in their application. In some cases, honest mistakes could still constitute a material misstatement especially if the information is relevant to your insurability.
However, some insurance companies act in bad faith by attempting to deny claims by the presence of a material misstatement even if the information involved has no relevance to your eligibility for coverage or your life expectancy. Whether or not your insurance company succeeds in avoiding payment entirely depends on your actions.
If you accept the denial on its face value and decide to take no further action, the claim will go unpaid, and your insurance provider will reap the benefits of mischaracterizing the inaccurate information. You would be surprised how often this happens. If you decide to fight the claim denial alone, your insurer will use its vast resources to defeat both your internal and external appeal. Hence, you need the services of a qualified and experienced attorney who handles denied life insurance claims cases.
- Clerical Errors and Incorrect Patient Identifier Information
Your medical claim must be filed with your insurer with the correct patient identifier information. Otherwise, your insurer will not be able to identify you in their system to make payment. A clerical error in your claim could cause it to be denied. However, such denials are usually resolved internally if you act on them immediately. Some common mistakes include a misspelled patient name, wrong ID number or birth date, or a missing subscriber or group number.
- A requirement for Prior Certification or Authorization
Many medical services that are considered non-emergency-related by your insurance company may require prior authorization. It is normal for many insurers to require prior authorization before you go for expensive services such as MRI, CT, and ultrasound. If these services are offered to you before prior authorization from your insurer, they will most likely be denied unless they were rendered as a medical emergency.
- Wrong Healthcare Provider
Sometimes your claim will not be approved because the insurance company wants you to use a different healthcare provider that the one you prefer. In this case, your claim will be approved if you select a different healthcare provider. You could try to convince your insurer that the provider you chose is the only one capable of giving you a particular service.
If you receive a life insurance claim denial notice or realize that your insurer is stringing you along by delaying making a decision about your claim, connect with an experienced advocate. A lawyer with a successful string of wins under their belt will give you a fair fighting chance against your insurer and get your claim approved.
Insurance Bad Faith Litigation
Every insurance company is required by law to treat its clients fairly and act in good faith. While this does not mean that your insurer must approve every claim they receive, it does, however, mean that they cannot simply look out for their interests by searching for ways to deny your claim to boost their profits. Even though each state has its set of insurance industry regulation, the general obligation of good faith exists everywhere.
An insurance company that acts in bad faith faces lawsuits with expensive consequences for their bottom line and public image. Moreover, the company faces penalties and fines from the respective state’s insurance commissioner. Your lawyer can help get your claim approved and also hold the insurance company accountable for its actions so that it does not continue with its bad faith practices.
Importance of an Insurance Denial Lawyer
Pursuing a bad faith insurance action is not easy. These lawsuits take a lot of resources, time, and persistence to follow through. You will also most likely be fighting against a team of seasoned corporate lawyers who will destroy your case at any chance they get. Below are some of the reasons you need to hire an experienced insurance denial lawyer as soon as possible:
- Insurance Law is Complex
As stated above, each state has a different set of insurance laws. Ergo, you need an attorney who is familiar with the laws that apply in your jurisdiction since they are in the best position to tell you whether your insurer acted in bad faith. Just because you read your insurance policy contract carefully and did some research pertaining to your claim’s denial does not make you equipped to argue your appeal especially in an external environment such as arbitration or a law court.
Since courts interpret those laws differently, your attorney will know how to proceed with your case to ensure the best possible outcome for you. Amount of damages allowed also vary from state to state. Thus, your attorney will know what amount to demand.
- Your Insurance Company is Well-Equipped to Fight Your Lawsuit
Insurance companies are used to fighting lawsuits and have experienced attorneys on hand for that. They are in the business of making profits and not paying out money to policyholders. This means that your insurer’s primary incentive is paying out less in claims than the amount they bring in in premiums.
Since a lawsuit will most likely give you more money if you win than your claim, your insurer will do everything in its power to fight you. They may also try to pressure you into either accepting a low-ball settlement offer or dropping your lawsuit. Your lawyer will advise you on the best course of action to take at every step of the way.
- Compensation and Attorney’s Fees
Many people fail to hire good attorneys because they feel that they cannot afford one. However, most insurance denial lawyers work on a contingency basis, which means that they will be paid a percentage of your award if you win the case. Some states allow you to recover attorney’s fees, punitive damages, and non-economic damages if you win the lawsuit. These options are beneficial especially when you are already struggling to pay your bills to let alone those that your insurer was supposed to cover before they denied your claim.
- Peace of Mind
Insurance lawsuits are tedious, stressful, and lengthy, which can leave you out of your depth if you decide to fight your insurance company alone. This situation is further complicated by the fact that you may be battling an illness (which is why you were seeking payment from your insurer in the first place) and you still have to pay your other bills.
Hiring an attorney allows you room to breathe and plan your lawsuit properly while still have time to continue living your life. Your attorney will follow your case on your behalf, advise you on what is needed at what time, file your papers correctly, and ensure that you do not miss important dates or issues.
- Saves You Valuable Time
If you think that your insurance claim was wrongfully denied or that your insurance company acted in bad faith, the first thing to do (after exhausting all internal avenues of resolving the issue) is to consult an experienced insurance denial attorney to find out whether or not you have a strong lawsuit to pursue. This will save you a lot of time and resources in the event that you have a weak case since your attorney will tell you, outright, all the facts of your case.
The Bottom Line
Whether you have been injured, diagnosed with a serious disease, or a loved one has died, the insurance claim process is tedious enough without having to deal with insurance bad faith practices or an uncooperative insurer on top of that. Also, going up against a well-equipped insurance company for its bad faith practices is most likely not something you are ever prepared for nor do you have the resources, time, or training to do so on your own.
Finding a Health Insurance Denial Lawyer Near Me
Stop Health Insurance Denial has qualified insurance denial lawyers with the experience required to take on any health insurance company in any state. Call us on 310-695-5241 to talk to one of our insurance denial attorneys or schedule a visit to our California head offices.