Anthem is one of the nation’s largest health benefits companies, serving over 70 million people, with over 50% of them being in the family of health insurance plans. This means that Anthem is the leading source of medical insurance benefits in the United States. However, Anthem also provides other related plans, including disability insurance benefits, long-term care insurance, life insurance, behavioral, dental, vision health benefits services, and flexible spending accounts. But even with such a massive consumer base, Anthem is no stranger to unlawful insurance denials.
Individuals and families purchase health care insurance for peace of mind and should they fall ill or get injured, they expect their insurer to step in and pay for medical expenses. Many people rely heavily on their health insurance in a way that even a small claim denial can result in substantial financial struggles. You followed Anthem’s rules and regulations when it came to paying your premiums, receiving health care, and submitting your claim. Then one day, you receive a telephone call or letter denying your claim. You may be worried, shocked, angry, and probably wondering if you should just accept Anthem’s decision concerning your claim or maybe there’s something else that you can do.
If your health insurance claim has been denied and you're in a state of confusion, you may be pleased to learn that health insurance carriers cannot just make their own rules as they go along. They’re obliged to follow both state and federal laws. If you believe Anthem is illegally denying your claim, you shouldcontact a knowledgeable and experienced attorney. An Anthem health insurance denial appeals attorney can help you appeal your claim. The attorneys at Stop Health Insurance Denial can work with you to advocate for your rights as a policyholder in order to get you the coverage you need and deserve.
Common Reasons Anthem Gives for Health Insurance Denials
Anthem, like any other insurance company, is in the business of providing health insurance and of generating profits. In some cases, health insurance giants may do everything they can to deny claims so as to protect their bottom line. This can be extremely enraging for policyholders who faithfully live up to theirduties and pay their premiums every time they’re due. Reasons for Anthem health insurance claims denials include:
The filing deadline has expired
The insured mad a late payment to COBRA
The medical device or treatment sought is not medically necessary
The treatment sought is experimental or investigational
The policyholder did not reach their deductible
The policyholder received two services in one day
The insured had a procedure or treatment that was not covered under the policy
The insured sought out-of-network services, whose benefits are different from in-network benefits
The person lacked a physician referral
As a medical patient, you trust your physician to recommend the most appropriate tests, procedures, treatments, and medical devices for whatever ailment you may have. Your doctor is trained, qualified, and has the experience needed to establish your medical needs. However, Anthem requires their policyholders to submit a pre-authorization request prior to receiving any treatment, procedures or purchasing any medical devices and supplies. But even so, they can deny your treatment and claim by stating that what your doctors have recommended or order isn’t medically necessary. While some denials are honest mistakes, most of them are completed intentionally and meant to look after Anthem’s bottom line. If you have experienced Anthem medical necessity denial, take back control of your health by calling a Stop Health Insurance Denial attorney.
Anthem Refusing to Cover Certain Medical Treatments
Insurance giant Anthem sometimes unlawfully denied claims for certain treatments and emergency room services, leaving patients with big medical bills. The denials are for ER visits that the insurance company deems “unnecessary.” Anthem policyholders may be scared to visit emergency departments because Anthem will decide after the fact what a real emergency is. Anthem can deny an ER claim if they later consider it to have not been an emergency. These actions violate federal law and can adversely affect patients with identical symptoms-such as chest pains, abdominal pains, difficulty breathing, blood in urine, and others-that may have deadly medical conditions.
The Legal Rights of Anthem Policyholders
What many consumers are not aware of is the fact that they can take action against Anthem when their claim is denied. Anthem is a commercial enterprise that is answerable to a higher command. However, the process to appeal a denied claim varies based on whether the insurance policy is governed by ERISA (Employee Retirement Income Security Act or 1974) or is a non-ERISA health insurance plan. Under 29 U.S. Code § 1132, ERISA controls employer-provided insurance plans, except in cases where the employer is a church entity or the government. Majority of the voluntarily established insurance plans are governed by ERISA. But an insurance policy purchased by an individual is not regulated by ERISA.
Under the federal law, Anthem as a health insurance company must provide its policyholders with detailed information, including the funding of the plan and the fiduciary duties. Insurance carriers are also obligated by this act to have an appeals process that policyholders can follow when contesting the claims denial. Policyholders also have the right to sue for coverage and the insurancecompany’s breaches of duty.
The process of challenging an Anthem insurance denial can be confusing and arduous. For this reason, anyone looking to appeal their claims denial may want the help of a seasoned lawyer to fight for their rights of an approval. The attorneys at Stop Health Insurance Denial can help increase your chances of acceptance for your claim of appeal.
Appealing an Anthem Health Insurance Denial
If Anthem denies you or your loved one health insurance coverage, it is important to know that you have the right to appeal the insurance giant’s decision. Being denied health insurance benefits from Anthem or any other insurer can have significant medical and financial implications. Fortunately, a skilled Anthem health insurance denial attorney canhelp you understand your rights and guide you through the complex appeals process.
To appeal an Anthem insurance denial, the insured person and his or her attorney should:
Understand the health policy:
This involves understanding whether the plan is funded by an employer or is self-funded, the type of plan it is, and the services covered under the plan.
Know the reasons for the claims denial:
By law, the insurer is required to indicate the exact reason why their claim for health care benefits was denied. In some circumstances, policyholders find that a simple error on their part or Anthem was the reason behind coverage refusal, and this may be quickly resolved by an internal review. In other cases, it may make sense to proceed with litigation and skip the internal appeal. This option is mostly applicable to individuals with a non-ERISA health policy.
Be aware of the time limits that apply:
Anthem and all insurance companies are beholden by state and federal law to issue a notice of claims denial to the insured party within 72 hours for urgent cases, within 15 days for a pre-authorization request, and within 30 days for medical services already received.
Collect all the supportive records:
Collecting all the relevant documentation before beginning the internal appeals process is an effective way of increasing the chances of getting the insurer to reconsider their decision. This step involves collecting copies of relevant medical records from the treating physician. These documents will serve as objective medical evidence to support the claim. The documents required can include copies of medical records, a letter from the physician, and independent research on a course of medication, treatment, or procedure.
What’s more, it’s important to gather documentation from Anthem. The insured person should also get to understand what their plan covers by requesting additional information on their health insurance plan. They should also collect documentation explaining the reasons for the claim denial. This may help one understand Anthem’s decision and can also help strengthen the appeal. It’s also important to collect documentation on the specific Anthem employee who denied the claim, including their name, credentials, and title. The information collected should also indicate whether Anthem consulted with ay medical experts when reviewing the claim as well as the medical criteria followed.
These are very important aspects because once an appeal is submitted, the die is cast. If you haven’t done everything or submitted all the important documents, it will all come back to haunt you. And should the case go to trial, the court will be looking at the claim file submitted by Anthem, so if your best evidence was never submitted, chances of losing the case are high. As such, you have to know when to consult with a seasoned lawyer when denied, instead of going through the process with no evidentiary support. Before saying the magic words “I appeal,” the lawyer should have fully developed the evidence to support the claim.
Filing an Independent External Medical Review
Some individual may get Anthem to change reconsider their decision and pay for medical care and treatment. However, there are instances where Anthem upholds its decision to deny the claim and should this happen to you, it’s important to know that you have the right to file an external appeal or an independent medical review from the proper state regulatory agency. An independent medical review request is done by an independent third-party such as a medical professionalor professionals skilled in evaluating whether Anthem’s decision was valid and supportable. Different states have different limits on policyholders who can request an external appeal. For instance, the State of California only allows policyholders whose claims were denied due to its determination that it was not medically necessary.
An individual can also request an external appeal if they have a serious medical diagnosis and Anthem denied payment for emergency or urgent care after the individual already received treatment. In order to support an independent medical appeal, it’s paramount to provide important documentation, including copies of the denial letters, a copy of any insurance card, a copy of the health insurance policy, any correspondence from Anthem, and any materials collected prior to filing an appeal.
Anthem Bad Faith
Health insurers such as Anthem usually make promises and assurance to policyholders when it comes to their benefits and the actions that they will take when a claim is made. Whenselling their products, Anthem will want to lure consumers by making it attractive. But when the policyholder falls ill or gets injured and it’s time for the insurer to live up the promises and provide the insured with the benefits as promised, Anthem mayfail to fulfill their end of the bargain. More often than not, they come up with tactics to cite obscure terms and ambiguous language found in the policy or just look for any loopholes to deny a claim that is legitimate or pay less than what the claimant really deserves. Depending on the facts of the case, this could qualify as “bad faith” interpretation of the health insurance policy.
Recovering Damages for Breach of Contract
A health care policy is a contract between the policyholder and the insurance company. When you purchase a plan with Anthem, you’re expected to pay your premiums each time they are due and Anthem is legally required to uphold the terms of their policy and pay for benefits in the event of a policyholder’s illness or injury. But if Anthem unreasonably denies coverage under the policy, the policyholder may be entitled to file a bad faith claim. This means that if a court finds that Anthem has engaged in bad faith by unreasonably denying a health insurance claim, the policy holder may be entitled to significant compensation for injuries and losses.
So, what kind of damages can an insured individual recover if Anthem breaches the insurance contract? The answer to this depends on whether the health policy is governed by ERISA or not. If governed by ERISA, the policyholder is only entitled to contractual damages, which are basically the coverage that was denied and potentially attorneys’ fees. Conversely, if the policy is non-ERISA, an insured may be entitled to extra-contractual damages, also referred to as tort damages. These can include damages for emotional distress, pain and suffering, physical injury, and potentially attorneys’ fees.
Punitive damages may also be awarded in such a case. Health insurance carriers such as Anthem may have company-wide policies that adversely affect insurance consumers. As such, insurance carriers engaging in bad faith practices may be punished through punitive damages. For a claimant to receive punitive damages, he or she must show that Anthem acted in bad faithand that the conduct was oppressive, fraudulent, and malicious. For instance, in late 2017, Anthem Blue Cross was fined $5 million for failure to resolve the complaints of their insurance consumers in a prompt manner. If you were unjustly denied an Antheminsurance claim or appeal, don’t give up and accept the insurer’s decision. An Anthem health insurance denial attorney can help you take legal action and force the insurer to give you the coverage you need
How to Calculate Damages
When determining damagein ERISA cases, the court typically looks to ascertain clear losses, usually those quantifiable damages such as medical care bills. In most cases, policyholders filing a claim are simply seeking to have their medical expenses paid as provided by the policy. Conversely, in non-ERISA actions, it’s paramount to examine whether an individual was affected in other ways in addition to facing health care bills, which involves examining the emotional and physical impact of an Anthem health insurance denial. For instance, if Anthem unreasonably denied a health insurance claim for surgery and the claimant ended up having complications because of they could not afford to pay for the procedure, the insurer could be held liable for any additional expenses.
Finding an Anthem Insurance Denial Appeals Attorney Near Me
Your hope of getting coverage may feel hopeless if Anthem has not lived up to the promises they made or has failed to fulfill their agreement with you. But don’t give up yet, you have legal rights and an experienced Anthem health insurance denials attorney who’s well-versed with Anthem’s duty towards you could help fight for your benefits. Working with a health insurer such as Anthem can be extremely exasperating and perplexing, especially if it involves a denied claim. Anthem and other leading health insurers usually find ways to justify their decision to deny a claim by alleging that a policyholder intentionally used an out-of-network provider, materially misinterpreted information, or the treatment was not medically necessary. What’s more, Anthem employs aggressive strategies and techniques to avoid facing an appeal.
Stop Health Insurance Denial could help you with the appeals process by ensuring that you have accurate and complete documentation for an internal appeal. Our attorneys could review your health insurance policy and draft a poignant and aggressive appeals letter. And if Anthem decides to uphold its decision to deny your coverage, we’ll guide you through an external appeal or we can file a lawsuit. Our knowledgeable and skilled attorneys will take the time to listen to your story and come up with the best legal strategy for your case. If you feel your ERISA or non-ERISA claim for health, disability, short-term care, long-term care, life or just aboutany other insurance involving Anthem has been wrongfully denied; contact Stop Health Insurance Denial at 310-695-5241 for a free, initial consultation. We’re here to help you stand up against health insurance giants and get you the coverage you need.