Following a major accident, it is crucial that you receive the necessary medical care for your injuries. If your healthcare provider keeps denying your claims, then you must seek out the best possible legal representation. Stop Health Insurance Denial serves clients located all over the country who have struggled to get their injury claims approved by their health insurance providers.
Insurance Claims for Serious Accidents
If you or a loved one is seriously injured in a serious accident, then your insurance provider will contact you in regards to your claim. This is also true if your loved one was killed as the result of the accident and, depending on the specifics of the case, this may qualify as a “wrongful death” lawsuit.
Filing a claim following a serious accident is generally done for two basic reasons: to pay for the damaged property and to seek out medical treatment for your injuries that were sustained due to the accident. Let’s focus primarily on the latter and consider what happens when your insurance claims for necessary medical treatment get repeatedly denied.
There are various types of serious accidents that would necessitate comprehensive medical treatment. Depending on your particular situation, there may even be more than one type of insurance coverage at play. The most common kinds of serious accidents are premises accidents, car accidents, product liability, dog bites, medical malpractice, and accidents caused by the other party’s gross and/or criminal negligence.
Of these various scenarios, the most common is a car accident. The injuries are usually incredibly serious and many victims become permanently disabled or even die. As a result, it is absolutely necessary that you always have ample coverage and the ability to quickly and effectively get your healthcare claims approved. The inability to do so may have grave consequences.
There are various reasons why your insurance company may deny your claims. Some of these may be legitimate and some may not. Furthermore, successful coverage of your post-accident medical condition also depends on whether your insurance company is acting in good faith (meaning that they denied your claim as an honest mistake) or in bad faith (meaning that they willfully and maliciously denied you coverage).
What if Two Different Policies Cover the Same Risk?
When you purchase any kind of insurance coverage, you are provided with a policy agreement. Legally speaking, this is a contract between you and your insurance provider. Because all contracts are legally binding documents under both federal and state laws, there are certain provisions that must be obeyed by both parties. For example, all contracts in the state of California must have all parties acting in good faith in order for it to be an actionable document. Failure to do so or the willful violation of said provisions is grounds for a breach-of-contract lawsuit.
This policy agreement also delineates the exact terms of your insurance coverage. Included in these terms is the protocol for what your insurance company will do if you have more than one provider covering the same risk. For example, let’s say you were in a serious car accident and you have both car insurance with a “bodily injury liability” provision as well as standard health insurance. Which one of these policies will cover the considerable healthcare costs you will incur during your treatment?
The answer is that this depends on the particulars of your given situation. Some insurance policies will make the payments on a “pro-rata sharing” model, meaning that the multiple providers will split up the payments amongst themselves. While this may seem to be optimal, it frequently results in chaos as your various providers bicker about who should cover what.
More often than not, the various providers will specify which is the “primary policy” and which is the “excess policy” (also known as the “secondary policy”). If a serious accident occurs, the car insurance policy of the at-fault driver acts as the primary policy until its benefit limit is reached. Once this occurs, the excess policy kicks in and picks up any slack. Furthermore, you will be required to pay the co-pay and deductible on both the primary and excess policies.
If the health insurance policy mistakenly paid first, they would then make a claim against the car insurance policy to recoup their costs. This means that insurance companies can file claims against each other, quickly making the entire situation overwhelmingly complicated.
All these provisions will be covered in your specific policy agreement. Because this is an ironclad contract between you and your provider, your insurance company will have to abide by its legal requirements and all its terms will be clearly delineated in its text. Always remember to read the fine print as your provider may try to trip you up with loopholes or technicalities.
As you can see, getting the right coverage following a serious accident can very quickly become overwhelming and prohibitively complex. Having a legal representative to help is a tremendous benefit, especially considering that they know the ins and outs of how these insurance companies operate.
Why Does Your Provider Keep Denying Your Claims?
It is absolutely imperative that you always remember one indisputable fact: the insurance company, and their insurance adjusters, are not your friends. They are not loyal to you and will always make the best decision for their bottom line. That is not to say that all providers act maliciously and deny coverage in bad faith – though this does happen and requires an insurance lawyer to help you file a lawsuit.
Following your serious accident, the insurance adjuster will reach out to you quickly. Remember that these adjusters are hired on the basis of their personalities and likeability; they will try to make you feel at ease and will push to resolve the issue as quickly as possible. They may claim to be moving fast for your benefit, but the truth is far more cynical: the insurance company wants to resolve the issue before the extent of your injuries becomes fully known and before you have had the chance to hire, or even speak to, an insurance lawyer.
Keep in mind that many injuries from a serious accident get worse as time passes after the incident; your insurance company knows this too and is trying to cut their losses to maintain their bottom line. It is in the insurance company’s best interest to give you a settlement before this happens, all the while denying your claims while accepting your premiums. This is how they stay profitable.
Having a provider deny a patient’s claims is quite common; in fact, the American Association of Retired Persons (also known as the AARP) estimates that approximately 200 million claims are denied each year. There are, of course, legitimate or semi-legitimate reasons to deny your serious accident claims. The most common are:
- Inaccurate and/or incomplete information; this is easily fixed and is a basic administrative error.
- Lack of prior authorization for coverage; in the case of a serious accident you may not have a chance to get prior authorization as you are in need of emergency medical treatment.
- Policy exclusion; certain kinds of injuries are not included in coverage policies. These are usually hidden in the fine print and, in some cases, may actually be illegal.
- Delay in treatment; the provider may deny your claim if you did not seek treatment immediately following the accident. They will argue that the injury cannot be that serious if you did not need a doctor right away.
- Failure to avoid injury; this denial basically argues that you are at fault for not acting in a way that would reasonably avoid injury, largely due to your negligence. This argument does not hold up if you are the victim of a car accident and the other party is at fault.
- Insufficient medical necessity; your provider will argue that you did not need the medical treatment. It is best to enlist the help of your clinician, along with your insurance lawyer, against this denial.
An experienced and skilled insurance lawyer can help you deal with these denials, particularly if your provider is rejecting your claims for illegitimate reasons or is using semi-legitimate reasons to block any progress.
Common Tricks Insurance Adjusters Use to Deny Your Claims for Serious Accidents
There are various methods that your provider may use to deny your claims as well as diminish or devalue your overall case. As always, it is important to remember that your insurance company has their best interests, not yours, at heart. The adjuster will make promises about getting a fair settlement and claim to be on your side, but this is emphatically not true.
Insurance adjusters frequently advise you against getting an insurance lawyer, claiming that it is not necessary and will only lengthen the process. This is a common tactic and you may find your adjuster frequently appealing to your sense of urgency and discomfort with the whole situation. Most people want the unpleasant aftermath of a serious accident to be over as soon as possible, but it is important to make sure that you get the coverage that you are entitled to. It is also common for the adjuster to try and reach a settlement immediately as a way of heading off future costs in your medical treatment. Be wary of this and remember to look out for your best interests.
It is also common for your adjuster to ask for a recorded statement immediately following the accident, even if you are still dazed from the impact or under the influence of painkillers. They try and get a recorded statement as quickly as possible so that they can start figuring what the cost will be to the company. There have even been cases when the adjuster asked the victim how they were feeling as a formality and then made the argument that treatment was unnecessary because the victim stated that they were, “Fine”.
Your provider may also ask for your medical records immediately. There may come a time where it is in your best interest to provide them, but this should be evaluated by your insurance lawyer. They will know best when and how to release that information to the adjuster. This is because your provider will try and claim that your injuries are due to a “pre-existing condition” and therefore not covered under your policy.
Stalling the entire coverage process is also used by some unscrupulous providers in the hopes that you will get overwhelmed and accept their settlement (which, by definition, is a lower amount than what you might actually need). They may also hold up the entire process by claiming small bureaucratic mistakes that require you to go through the whole application process again.
Finally, your provider may go to great lengths to disprove your claims. It is not uncommon for these companies to hire private investigators to surveil you to try and prove that you are not really injured. These private investigators are not medical professionals, making them fundamentally unfit to determine your health, and any “evidence” that they gather can be distorted by your provider to justify their denials of your coverage.
A nonprofit watchdog group known as the American Association for Justice has released a list of the top 10 worst offenders:
- Allstate Insurance
- American International Group (widely known as AIG)
- State Farm Insurance
- United Health
- Farmers Insurance
- Liberty Mutual
These insurance companies frequently use unsavory tactics to justify repeatedly denying their customers’ claims. This type of behavior falls along an entire spectrum, with some providers acting unethically while others fully break the law. Always remember that your insurance company is more concerned about their bottom line than your health or wellbeing.
If you feel you are being treated unfairly or outright cheated by your insurance provider, you need to seek out an insurance lawyer who can determine where in this spectrum your situation lies. Once you have determined that, they can help you build your case and make progress. You may even be entitled to financial compensation if the misconduct you suffered is particularly egregious.
What Should You Do If Your Claim For a Serious Accident Is Being Denied?
There are several steps you can take if your claim for a serious accident is being denied. First and foremost you must determine why the insurance company is denying you. They will give you a reason in writing, most frequently one of the six reasons listed above.
However, sometimes you might have to do a little detective work and read between the lines; this means you should be skeptical of what they claim and remember that they care about profits, not you. You should call and politely speak to your insurance company directly, but remember that the call will be recorded and that you should be taking notes about the exact content of the call to later share this information with your insurance lawyer.
You should also enlist the support of some involved parties, such as any of the clinicians who treated you following the accident. In many cases, they can more effectively make the case for why you may need some procedure and/or treatment. Your health may be at stake, so it is important that you have the experts, not the insurance adjuster, determining your fate.
Additionally, many hospitals and even some clinics have social workers in their employ who deal directly with health insurance companies. They are usually particularly effective in dealing with Medicare and Medicaid, though they will be able to act as your representative for any medical claim. It is their job to eloquently and forcefully make your case and they should be considered an invaluable resource.
It may also be helpful to apply repeatedly. Insurance companies will always try and reduce their risk while maximizing profits. In order to do this, they frequently use auditing software to automatically parse through millions of claims. This is effectively the first wall of defense for the provider and, in many cases, the software unfairly denies the claim.
If you have been denied repeatedly, you may always appeal. There are several avenues you may take, starting with an “internal appeals” process. Hold on to every piece of paperwork that you have accumulated throughout the process and then present it as part of the internal appeals. The specifics of this process will be provided to you by your provider or as part of the paperwork in your policy agreement.
If the internal appeals process fails, then you may take it to an “external review”. This is the next step and the particulars of its protocol also depend on your policy agreement as well as where you live. How this process is done varies from state to state and it is best to have an insurance lawyer guide you through all these conflicting regulations and rules. Whatever the specific outcome of the external review is, your insurance provider will be legally bound to obey its provisions.
If all else fails, you may always take to the courts to determine your case. Your lawsuit can be filed on the federal or the state level and your insurance lawyer will counsel you on what the best strategy is. Furthermore, if your insurance provider is being especially malicious in denying or stalling your healthcare claims, then you will have an excellent case that they are acting in bad faith and you may file a lawsuit to claim substantial damages. Acting in bad faith is a violation of state and federal laws as well as a breach in the provisions of any legitimate contract.
Where to Find An Insurance Denial Attorney Near Me
A serious accident should never be taken lightly; it requires immediate attention and medical treatment. Do not let your health and wellbeing rest in the hands of your insurance company, especially if they are unscrupulous or unsavory in their dealings with you. Claim your complimentary consultation from Stop Health Insurance Denial by calling 310-695-5241 right away!