If you have health insurance, then it means that you have purchased a service meant to ensure assistance with any future health issues or accidents. With a health insurance policy from any company, you expect to receive all of the benefits that you buy into it. Usually, as a policyholder, you receive coverage and assistance with medical expenses. This may mean paying reduced payments on medical bills and having the ability to go to certain doctors and health care providers in your area. Throughout the nation, there are many insurance companies to choose from and each company has its own benefits; thus, people take special considerations when selecting an insurance company and a policy.

Unfortunately, there are times in which doing business with insurance companies may be complicated and frustrating—especially when it comes to insurance claim denials. Simply, this means that your health insurance company has decided not to cover any part of your claim, such as a medical bill. When this occurs, it can become a stressful situation for anyone. However, if your insurance claim has been denied, you can contact Stop Health Insurance Denials for help in these situations. Our team of professional insurance attorneys can assist you with any matters related to insurance claim denials. We want to hear from you if you have faced a denial, or if you any questions regarding a denial. You do not have to be alone in the process.

What Is an Insurance Claim Denial?

As an insurance policyholder, a claim denial is something that you never want to be faced with; however, it does often to many people. An insurance claim denial is basically a notification from your insurance company stating that they will not pay the whole claim or a part of it. This indicates that you will not receive coverage for any services that you have been billed for by a health care provider. This can quickly become a stressful situation for anyone—especially since medical bills can be quite expensive.

An insurance company may deny a policyholder’s claim for many reasons. If this has happened to you, it is also crucial to be notified about the reasons for denial and what they mean. If you do not completely understand the reasoning behind the denial, or if it is confusing, you may always ask your insurance company, your doctor, or your hospital for clarification. For insurance policyholders, the most common reasons for denial include:

  • The services or procedures received are not covered under your policy;
  • The procedure you received was considered experimental, cosmetic, investigational, or not medically necessary;
  • A referral or pre-authorization was required beforehand;
  • The health care provider was outside of your policy’s network;
  • Typographical errors;
  • Time-related issues; or
  • Other policy limitations.

This is a limited list of common reasons for insurance claim denials. Most of these reasons can be appealed, or fixed through other means as described below. Of course, as an insurance policyholder, your hope is that any claim you may have is never denied. However, this may not always be the case. When your claim is denied, you may be unsure of what to do next, and the options you have available.

What Options Do You Have If Your Insurance Has Been Denied?

Often times, when your insurance claim has been denied, you may feel that it has been denied unjustly, or without proper reason. Even when companies do provide a reason for denial, like those listed above, you may still feel it is unjust. Once your claim has been denied, you can still fight against it. Once you have identified the reasoning behind your claim denial, you can proceed in determining how you can fight against it.

Once you have received notice that your claim has been denied by your insurance company, the first step you should take is making a note of any questions you have regarding the denial. Also, you should gather any documents and materials related to your policy and the claim, like the policy itself and the notice of denial. After this preparation, you should contact your insurance company about the issue. Since this is the source of the problem, you should always contact them first. There may be situations in which you have been denied due to a simple error. If the phone call to the insurance company does not help you with your situation, you still have more options available.

Reading Your Policy

All insurance companies are required to provide a list of benefits and coverage regarding any policy. By reading through your policy, you can get an understanding of your rights and responsibilities as a policyholder include. Also, the policy will describe what is covered and what health care providers are included in your plan.

Often included in your policy is information regarding the procedure for appealing a denial should it occur. There are two different ways in which an appeal may be carried out. The first method of appeal is done through the insurance company itself. The second method may be done by an external third-party.

Appealing the Denial

If you find that contacting your insurance company through a phone call proves to be unfruitful when reversing the denial, there are other methods through which you can fight against the company’s decision. Namely, this can include appealing the denial decision with the company.

When your insurance company has denied your insurance claim, you may respond to their decision with an appeal. Through this action, you will write a letter, or another form of communication, to your insurance company containing your arguments against the denial. Usually, when composing your appeal, you should try to be as detailed as possible. Along with the arguments, you should include any documentation or evidence to back your argument. With an appeal, you will directly focus on the grounds of denial that your insurance provided you with. This may mean including an explanation for why the service or procedure is necessary and should be under your insurance policy. Also, you may include any other materials like lab results, x-rays, or a letter from your doctor or any of your health care providers explaining why the service/procedure is necessary. Also, if the denial proves to be life-threatening, you may even ask to get your appeal expedited. As with any other interactions with your insurance company, you should keep copies of any and everything that you send regarding your appeal.

Under the Affordable Care Act (ACA), there are certain requirements that an insurance company should adhere to when responding to your appeal within a certain amount of time. They should respond within:

  • 72 hours if the denial is regarding urgent care;
  • 30 days for services or procedures you have not received yet; or,
  • 60 days for services or procedures you have already received.

Your insurance company should respond to your appeal within a well-reasoned amount of time. Once they do, they should provide what steps should be taken next and any follow-ups. If the appeal proves to be unsuccessful and if the company refuses the valid claim, then you may be able to take legal action.

Third-Party Review

If your appeal through your insurance company proves to be unsuccessful, then you may request an external review of your appeal. Usually, this may be done by a third-party (meaning neither you nor your insurance company).

When your insurance company sends you a notification regarding their decision, even after an appeal, they will include information pertaining to filing for a third-party review. Usually, once this has happened, you will have around sixty (60) days to file a request. Each insurance company may have a different process for filing for an external review. All insurance companies must allow for this option; however, some may only allow it after you have gone through an internal review first.

Once a decision has been made by the third-party (usually this occurs within 60 days), your insurance company legally must accept whatever the outcome may be.

Bad Faith Insurance Denials

Unfortunately, there may be situations in which your claim is denied due to unfair practices committed by your insurance company. When this does occur, you may feel that you cannot change the outcome and that you have been cheated out of receiving your proper benefits. All insurance companies are required to act in good faith and follow through with the agreements made with their customers.

If you have been unfairly denied coverage or benefits, then you have the option to file a lawsuit in order to fight against the decision. When insurance companies go against what they promise to do as stated within their policies and agreements, customers may file a breach of contract lawsuit. This is a common tactic for customers to use when they have been unfairly denied by their insurance. Besides sticking to the contract, insurance companies have a responsibility to deal in good faith towards their customers. If this is not so, then a customer may also file a lawsuit. To better understand these legal options, we will look through reasons to take legal action against your insurance company.

Bad Faith

When it comes to dealing with customers, all insurance companies have a duty to deal in good faith and fair trade. This simply means that insurance companies have a responsibility to act in accordance with any contracts made with customers and to guarantee any and all benefits and coverage that may have been promised. This can mean that when your insurance company has denied a claim that should have been covered under your policy, it is considered to be acting in bad faith. This may occur if your insurance company has:

  • Fabricated any evidence pertaining to your claim;
  • Refuses to accept evidence pertaining to your claim;
  • Refuses to conduct an investigation into your claim;
  • Delays an investigation for an unreasonable amount of time;
  • Does not respond within a well-reasoned amount of time;
  • Adheres to minor procedural or bureaucratic requirements in an unreasonable manner; and,
  • Acts in any way that may be considered bad faith.

Through these unlawful behaviors, an insurance company may withhold any proper benefits or guaranteed coverage for the sake of saving money. These are methods insurance companies often utilize in order to get out of paying for their customers’ claims. Usually, an insurance company uses bad faith practices in order to avoid following through with their responsibilities as an insurance company. If you believe that your health insurance company is withholding your benefits or coverage for an unreasonable reason, then you may file a complaint or take your case to court.

Filing A Complaint

If you feel that a health insurance company has wrongfully denied your insurance claim, or if they are acting in bad faith, then you may be able to file a complaint. Each state has its own Department of Insurance or any similar government agency. Also, each state may have different procedures for filing a complaint and what is required of you in the process. It is crucial to locate your state’s own insurance department and to find out what the process entails.

By contacting your state’s insurance department or filing a complaint with them, you may have to endure a long and complex process during which your claim and your insurance company is investigated. Then, you may have to come to an agreement with your insurance company with the assistance of government workers. This sort of action may lead to a reversed decision by your insurance company. If this fails, or if you want to skip this process, you may seek legal assistance from an insurance attorney.

Legal Help

With the guidance of an insurance attorney, you may be able to take your complaint to court. It is crucial to know that each state has different laws regarding insurance practices and what may constitute bad faith practices. With an attorney, they can help you understand what your state’s laws are and what to do next to resolve your issues. They will also help in making sure that your rights as a policyholder are not violated at the hands of your insurance company.

With an insurance attorney, they will help you determine if your insurance company has wrongfully denied your claim and has done so in bad faith. With their expertise, they will identify the issues and help to resolve them in court. They will go over the details of your situation and look to see if they have committed any actions similar to those described above and which may be considered bad faith. Usually, if your insurance claim has been wrongfully denied, it may be taken to court as a breach of contract. This simply means that your insurance company has gone against what they have promised to you under your policy. By wrongfully denying your health insurance claim, or by denying a part of it, your insurance company may be liable. Usually, these types of lawsuits end with a settlement from the insurance company, an arbitration decision, or a different verdict depending on the circumstances.

Besides a breach of contract, an attorney may even ask for a tort claim. This simply means that your insurance company acted in bad faith regarding your claim. More than just reversing the company’s decision about your claim, with a tort claim you may also be able to receive damages and compensation for the company’s unlawful actions. Remember: all cases are different. You may receive a different outcome depending on the details and circumstances of your case.

Finding a Health Insurance Denial Attorney Near Me

Has your insurance claim been denied? Have you tried fixing this issue with your insurance company with no success? Do you believe that your insurance company has been acting in bad faith? If you have any of these questions or more, you should contact Stop Health Insurance Denials today. When your health insurance claims are denied, it can be stress-inducing and especially frustrating since it pertains to your well-being. You should always receive the benefits and the coverage that you signed up for and that was promised to you by the insurance company. More than this, you should not be left to suffer financially or health-wise because your insurance company refuses to accept your health insurance claim.

Even though health insurance companies seek to make profits as with any other type of business in the nation, they do have certain responsibilities to uphold with their customers. Especially since customers place a lot of trust in their health insurance companies, all customers want to receive the best services and benefits. Unfortunately, health insurance companies often leave customers on their own without their assistance. This is not right. With an insurance denial attorney, we can fight for you and make sure that you receive the benefits that were promised to you. Our attorneys are highly qualified and experienced in the field of insurance law. If you need help, contact us at 310-695-5241. Call us as soon as you can so we can review your case and get started right away.