Insurance companies all across the United States deny services to their policyholders on a daily basis. Like any other business, insurance companies are out to make money not spend it. To make money, insurance companies deny certain services to certain individuals with the hopes that they can avoid having to pay for a cost. This means that some people are not getting the health treatments they require solely because the insurance company is trying to save money. While insurance companies are allowed to deny services (for legitimate reasons), it is their lawful obligation to uphold the provisions of the contract that exists between the insurance company and policyholder. This means that when an insurance company denies a claim, they are required to explain why. Additionally, they are required to do so in a timely manner.
When insurance companies deny insurance coverage it is for a variety of reasons. Some reasons can include the following:
- Your health concern is not covered by the health insurance. This means that your insurance agreement is not legally required to provide coverage for your specific health concern or for a specific treatment.
- You have a limited coverage meaning the insurance company can only cover up to a certain amount. Insurance companies will include coverage for certain health concerns or treatments. Health insurance companies are not required to cover the full cost of a specific treatment unless it is otherwise stated in the health insurance agreement.
- Your health insurance does not cover the amount of money required to cover the medical costs. There are various health insurance plans that cover different types of costs. To ensure you receive coverage for specific treatments you may want to work with an insurance policy that covers your specific concern.
Your health insurance company is not obligated to cover all of your health concerns; however, if your health concern is clearly stated in your insurance contract then they have an obligation to keep up with their promise. In other words, if your health insurance states it will cover the cost for a certain treatment, then they are legally obligated to do so. When insurance companies refuse to cover a cost it’s either because your specific health concern is not mentioned in your insurance policy or because your insurance company is interested in saving money. When it is the latter, it is crucial that you document every step of the insurance coverage denial.
When your health coverage is being denied and you are suspicious of the action, it is best to ensure that you document every conversation. It is recommended to either send letters with dates or electronic mails to ensure that the date appears on the conversation. Whenever your insurance company acts in an unlawful manner keeping track of your conversation with your insurance company will allow your legal representative to make a case for you. There are many unlawful practices that your insurance company engages in to save a penny.
First and foremost, you should inform yourself about the bad faith practices that are most common with insurance companies. Bad faith practices include:
- Not getting back to your mail, email, or phone calls in time: according to the California law, an insurance company should get back to their policyholders whenever a claim is made within fifteen days. More than fifteen days would be considered a bad faith practice. Often times, when a health insurance company wants to avoid paying health costs, it will attempt to prolong the process so that you pass your statute of limitation. After you surpass the status of limitations the insurance company cannot be sued, and you will not be able to make a claim to receive coverage.
- Requesting unnecessary documents: as mentioned above, insurance companies will try to prolong the claims process with hopes of surpassing the statutes of limitations which means they will not be required to process the claim. In some cases, an insurance company will request unnecessary documents (documents that are not required) in order to prolong your case. Often, these documents are difficult to obtain which is why an insurance company will request these documents in hopes of prolonging your case. For instance, they may request a document with information that was already explained with another document then it is clear that they are trying to buy some time. The more time they can waste the better it will be for them in return. Though the document may be required, if the information on the document they request has already been provided then it may seem like a bad faith practice under the law.
- Making threats: if your insurance company is making threats to you or treating you without respect; then, you should know that the insurance company is not treating you as it should under the law. When an insurance company begins to make threats or begins to mistreat you, the practice may be seen as bad faith. There is no reason for an insurance company to use scare tactics to prevent you from filing your claim. If your insurance company is attempting to scare you away from making a claim it is clear that they are up to something. If this is the case, it is time to contact a legal representative.
- Denying your coverage request without legitimate reasoning: Ideally, when an insurance company denies a request, it means the insurance company has thoroughly investigated your case. Denying coverage requires that the insurance company research the claim and provide reasoning as to why the coverage has been denied. It is seen as a bad faith practice whenever an insurance company fails to properly investigate a case and denies a claim without a legitimate reason.
A health insurance company is required to respond to a coverage claim in good faith. Under the insurance laws in the United States, insurance providers are required to treat their policyholders with fairness and with respect. Whenever an insurance company acts in bad faith, there are several ways you can fight for coverage. If you have good reason to believe that the insurance company has acted in bad faith, it is crucial to speak with a third party. An insurance law expert may fight for your case in a courtroom. Commonly an insurance company can be taken to court whenever they fail to uphold the status of the insurance agreement.
Like any other agreement, when either party fails to uphold the provisions of an agreement, the policy can be discussed in a courtroom. If you wish to learn more about your rights as a policyholder and you want to learn more about the ways in which you can receive coverage after it has been denied, you may want to speak with an attorney about your case. There are a number of laws that protect the policyholder ensuring that their rights are preserved. To speak with a local law expert on health insurance agreements, you may contact the Stop Health Insurance Denials at 310-695-5241. We are ready to hear your case and provide the next steps to claiming the coverage that is rightfully yours.
The next section will discuss in more detail the rights of the policyholder. Keep in mind that every case is different and should be consulted with a law expert. The following is a broad interpretation of the law that may not apply directly to your case.
Rights of the Insured
There are a number of rights that pertain to those who are insured and to those who are seeking insurance. The federal laws touch on the following topics with regards to health insurance:
- Pre-existing health conditions
- Insurance while pregnant
- Preventative Care
- Young Individuals seeking insurance coverage
- Understanding the type of health insurance that you get
- Canceling health insurance
- The right to choose your own doctor
- The right to health insurance when you are sick
- Employer retaliation protection
When it comes to health insurance there are a number of policyholder rights that you should be aware about. The following section will take a closer look at the topics mentioned above. Keep in mind that this is a broad interpretation of the law. To ensure you are receiving the information that pertains to your specific case it is advised to consult with your local attorney about the specifics of your case.
Pre-Existing Health Conditions
Those with pre-existing health conditions can no longer be denied coverage. Since 2014 insurance companies can no longer deny health insurance coverage to a person with a pre-existing medical condition. Additionally, they may not raise the cost of insurance for a pre-existing medical condition. Furthermore, once you are insured the insurance company cannot reject coverage or raise your contractual payments based on your health condition. Whenever an insurance company rejects coverage or attempts to raise insurance costs for those with pre-existing medical conditions it should be noted that they are not acting within the laws that guide medical insurance.
Though an insurance company cannot legally deny you coverage or raise your insurance payments, keep in mind that this does not apply to "grandfathered insurance plans". Grandfathered plans are not required to cover pre-existing conditions or required to provide coverage for preventative care. If you are in a grandfathered insurance plan you have the option to switch insurance policies during open enrollment.
Health Insurance for the Pregnant
A person that is undergoing pregnancy may not be denied health insurance. Like with pre-existing health conditions, the insurance company may not raise the costs of the insurance based on the conditions of the pregnant individual. This means they are obligated to provide coverage once the individual has been insured. Three things to keep in mind:
If you are pregnant at the time you are seeking insurance coverage, the insurance company may not deny services to you based on your pregnancy. Under the health insurance laws, the insurance company is required to provide coverage.
Additionally, at the time of the child's birth or if you have chosen to adopt, the individual will be granted the right to change plans (if they desire to do so) outside of the Open Enrollment Period. This is called the Special Enrollment Period and it applies to those who are pregnant or who are have adopted a child.
Finally, coverage for your child begins the day after he or she is born or after the child has been adopted. This is true even for those who are late in enrolling (up to 60 days after the birth of the child or after the child has been adopted).
Preventative Health Services
Your insurance company cannot deny policyholders the right to preventative health services. Preventative services can include screening tests and shots. There are different types of preventative services that apply to children, women, and all adults.
All Adults: an insurance company cannot deny adults the right for preventative care services that include: blood pressure testing, alcohol misuse screening, one-time screening for aneurysm, cholesterol screening, cancer screening, depression screening, diabetes screening, screening for hepatitis B or C, HIV screening, Immunization vaccines, screening for Sexually transmitted diseases, and Tuberculosis screening.
For Women: an insurance company cannot deny women preventative care services that include: screening for anemia, folic acid supplements, screening for diabetes, breastfeeding counseling, screening for gonorrhea, screening for hepatitis b, screening for syphilis, screening for high blood pressure, screening for breast cancer, screening for cervical cancer.
For children: an insurance company cannot deny children the following preventative care services: screening for autism screening, behavioral assessments (till the age of 17), blood screening, fluoride varnish, gonorrhea medication, Height, weight, and body mass index (BMI) measurements, and sickle cell screening
Young Individuals Seeking Insurance
If you are a person under the age of 30 there are a number of ways that you can get health insurance. Those under the age of thirty may qualify for the Special Enrollment Period whenever they get married, lose coverage, or when they have a child. Furthermore, those under thirty may seek for Medicaid coverage and Children's Health Insurance Programs for their child. A person that is under the age of thirty and earning less than $17,000 a year may seek Medicaid coverage. Married individuals with no children may seek Medicaid coverage if they earn less than $22,715 a year. Additionally, if you have a child, the child may qualify for Children's Health Insurance Programs even if you do not qualify for Medicaid.
If the individual is under the age of 26, he or she may remain part of their parents' insurance policy. On the other hand, a person under the age of 30 may apply for insurance that is based on their income. The government understands that many individuals under the age of thirty making enough to pay for rent and for other life essentials. For this reason, the government allows those under the age of thirty the right to seek insurance based on their income. This type of health insurance is called "Catastrophic" health plan and it is meant to provide coverage in the worst of cases.
Understanding Your Health Insurance
Health insurance agreements can sometimes be long and difficult to understand. The law requires that health insurance companies provide a plain English summary of your health insurance plan including the benefits and the coverage. Upon request, the insurance company is required to send you a summary of your benefits and coverage. Additionally, they must include a glossary of the terms used within the insurance agreement. Easy to understand health insurance summaries can be requested at any time and it includes any type of health insurance including grandfathered plans.
Canceling Health Insurance
It is against the law for health insurance companies to cancel their coverage when you make a mistake on your application. Prior, a health insurance company could deny coverage if they found that you have made a mistake on your application. However, keep in mind that your insurance policy may be canceled whenever you fail to provide accurate information. Additionally, your policy may be canceled if you fail to make your payments.
Right to Choose a Doctor
- You have the right to choose the doctor you want to be attended by. This means you can choose a doctor within the health insurance plans network.
Protection from Employer
- It is against the law for an employer to fire an employee for the following reasons:
- You bought a market place health insurance plan and you have received premium tax credits
- You have reported a violation of the Affordable Care Act to the Occupational Safety and Health Administration (OSHA).
Find an Insurance Expert Near Me
If you are living within the United States and you have been denied health coverage, you may speak with a legal representative. A legal representative is capable of assessing your case to ensure that your insurance company has denied coverage with good faith. An insurance company that acts in bad faith and fails to uphold the provisions in the insurance agreement may be brought to court.
To speak with an insurance expert, you may contact the Stop Health Insurance Denials at 310-695-5241. Our health insurance attorney is ready to help you with your case and get you the coverage you deserve.