Many people across the nation go through long processes in order to determine what insurance companies and policies fit for them. Usually, this means going over an insurance company’s track record and the benefits and coverage that they would receive under their policies. This is done in order to determine if they can trust that their insurance company will be there when they need it the most. After all, health insurance can be a vital product to anyone who has a medical emergency or an accident. Since these companies deal with services pertaining to your health, they have certain protocols and processes to go through when conducting business. When it comes down to insurance claims, it is important to understand what your insurance company is meant to do for you.

When it comes to working with a health insurance company, you may be unsure of what they are supposed to do for you. As a health insurance customer, you have a right to receive fair treatment. It is important that you know what duties a health insurance company is required to undertake. With this information, you will be able to determine if you may have been treated fairly and lawfully. If not, then you may receive help from Stop Health Insurance Denials. When you are faced with health insurance denials, it is crucial to understand your health insurance company’s responsibilities.

What Are the Duties of a Health Insurance Company?

Any business related to health insurance is a highly sensitive matter for anyone. Not only do health insurance customers expect to acquire all the benefits and coverage they have bought into, but they also expect simple things like timely responses. Of course, there are certain procedures and business practices that all health insurance companies must follow due to the nature of their business. There are even laws meant to ensure all policyholders are treated fairly and that insurance companies do not take advantage of their customers.

There are a couple of important duties and responsibilities that all insurance companies have and that you should know about. By knowing these, you may be able to know if your insurance is taking advantage of you or if they are wrongfully denying one of your insurance claims. Many of the responsibilities are meant to coincide with the rights of policyholders. These duties include:

  • Communicating any, and all, necessary information regarding your policy;
  • Not discriminating against their customers;
  • Properly investigating, processing, and paying claims;
  • Responding to your claims, or other issues, in a reasonable amount of time;
  • Informing customers of any and all deadlines; and,
  • Allowing customers to appeal their claims decision.

All of these responsibilities are meant to ensure that insurance policyholders receive services that are meant to help them and so that they receive the services that they have purchased. Also, these duties are meant to keep insurance companies from taking actions that may be considered bad faith. Of course, there may be state laws requiring insurance companies to do certain things, so it’s also important to research what rights you have and what laws there are in your state.

Fair Dealing & Good Faith

All health insurance companies have a responsibility to practice their business in good faith and with fair dealing. This can mean adhering to its contractual obligations towards you and your policy. This is a kind of protection for the policyholder when it comes to issues with the insurance company. Fair dealing and good faith are a simple way of saying that insurance companies must treat their customers reasonably and with fairness. Simply, good faith requires honesty and adherence to promises made. With something like health insurance, it can be easy for insurance companies to take advantage of their customers.

In some states, there may be laws that seek to make sure insurance companies act in good faith. It can vary from state to state so it is important to look up the laws in your state. However, these are all meant to protect what can be called policyholder rights—the rights of individuals who have health insurance policies. When insurance companies go against these rights or laws, it may be considered to be acting in bad faith.

Communicating All Necessary Information

The foremost, and most logical, of an insurance company’s duties include making sure that all necessary information is communicated with their customers honestly and accurately. This has many parts to it. When it comes to purchasing a policy from an insurance company, you should be notified of any and all information regarding your policy. Usually, when shopping around for a health insurance policy, most people will want this information in order to pick out a policy that will best fit them.

Health insurance companies cannot misrepresent any facts regarding your policy. This can include information like the benefits you would receive, the coverage under the policy, doctors/health care providers within the policy’s network, and more. By misrepresenting this information, an insurance company provides false information about their product. More than this, by giving information that is not accurate about an insurance policy, it may mislead customers into purchasing a policy that may not actually work for them; thus, the customers would suffer.

Example:

  • John purchased a specific insurance policy because the company listed his usual doctor within its list of in-network providers. However, once John visited the doctor after purchasing the policy, he finds out his doctor is not actually within the policy’s network.

This is an example of providing inaccurate information to policyholders. John thought he could keep going to his regular doctor, but the health insurance company’s false information led him into purchasing a plan he would not have wanted. Besides this, he may be made to pay the medical bill out his own pocket.

Your health insurance company should also communicate with you about your rights as a policyholder. Usually, when you initially purchase a policy you will be notified of all of this information. You should also be given all of the details about your policy’s benefits and the coverage you will receive. Even when your coverage or benefits has changed in any way, you should always be notified. With this information, you will know if your claim can be approved.

Proper Claim Investigation

Probably one of the most important duties that a health insurance company has is claim investigation. A claim investigation is when the insurance company evaluates an insurance claim by obtaining any and all necessary information. This can mean the insurance company obtains medical records and any documents the doctor or health care provider may provide. Usually, a claims investigation is undertaken so as to make sure that the services you seek are in fact covered under your policy. The outcome of a claim investigation will either be an approval or denial depending on the information obtained. In most cases, your health care provider will submit the health insurance claim directly to your insurance. Once your insurance receives it, they will verify if the service is covered.

Example:

  • Patricia submitted a claim to her insurance company after visiting her health care provider. After waiting for weeks, her medical bill was due, and she still had not heard from her insurance on whether her claim was covered or not. Instead of having her insurance cover the costs, Patricia ended up paying the bill out of her own pocket.

When it comes to a claim investigation, your insurance company does have certain responsibilities. Namely, insurance companies must respond to the claim within a reasonable amount of time with an answer. Also, your insurance must follow its standard process of investigating claims. These duties are meant to ensure that customers receive fair and equal treatment, and a timely response so that they may proceed with their health services.

Also, within this investigation process, your insurance should make sure that claims end in a settled amount that is described under their policy. This simply indicates that all customers should be covered for what they believed they are covered for as described under their policies. Your insurance may not cover any less than what they promised to cover. Without valid reasoning, your insurance may not shortchange you on your benefits and coverage when it comes to your claims.

Providing Valid Reasoning for Denial

When you submit an insurance claim, you will wait for either an approval or denial. In some cases, you may be denied. When this does occur, your health insurance company must provide a valid reason for denial. Usually, they will send a notification with this information. Common explanations for denials include:

  • Services and/or procedures are not under your insurance policy;
  • A procedure is considered investigational, cosmetic, experimental, or not necessary;
  • There needed to be a referral or some pre-authorization;
  • Doctor or provider is not listed in your policy’s healthcare network;
  • Time-sensitive problems; or,
  • Other types of policy limits.

The above represent valid reasons for a claim denial, and there may be others depending on your circumstances. An insurance company must always provide a reason for why your claim has been denied. If they do not, then they may be liable. Also, if they fail to give you a denial and reasoning within a reasonable amount of time, they may still be liable. Once you have received reasoning for why your claim was denied and you feel it is still unjustified, then you may appeal the decision with your insurance.

Allowing an Appeal

Once your insurance claim has been denied, or partially denied, then you have the right to appeal the decision should you feel it was unjustified. One of the duties that insurance companies have includes allowing an appeal as it is the right of the policyholder. Usually, an insurance company will provide its policyholders with information regarding how to appeal the decision. The process usually begins with the policyholder submitting a letter regarding the decision, informing the insurance with why they believe their denial was unjustified. This is the policyholder’s chance to argue their position when denied.

When you have submitted an appeal to your insurance, they also have a duty to respond with an answer within a specified amount of time. Again, this may vary from state to state. Once you have received the answer to your claim appeal, and you still do not agree with it, you may proceed to submit for review from a third-party. Once again, your insurance must allow you to seek a review of an appeal by a third-party. Often times, this is allowed after you’ve already gone through the insurance itself. The insurance must honor the third-party's review and their decision.

Bad Faith Practices

An insurance company’s duties reflect actions done in good faith. However, when an insurance company fails to perform these actions, they may be acting in bad faith towards their customers. This indicates that the insurance has failed to fulfill its promises towards its customers, and has taken advantage of them. Common examples of bad faith practices include, but are not limited to:

  • Misrepresenting information regarding policies, benefits, and coverage;
  • Not responding to claims, inquiries, and more within a reasonable amount of time;
  • Not properly investigating or processing a claim;
  • Not providing a full settlement as described under a policy;
  • Changing policy details without policyholders’ awareness; and,
  • Delaying responses about a claim or when inquiring.

Most of what can be considered a practice of bad faith can also be seen as violating the rights of the policyholder. These types of practices are the means through which insurance companies may take advantage of their policyholders. Also, these are means through which they seek to avoid fulfilling their responsibilities and save money on insurance claims. If your insurance company has committed one of these actions, or one similar in nature, during the claims process, they may be liable.

What to Do If Your Insurance Company Does Not Follow Its Duties

If your insurance company has failed to fulfill any of these duties, then it may mean they have violated your rights as a policyholder. If this does occur, then you still have options to fight against an insurance claim denial. These include filing a claims complaint against the insurance company with your state’s insurance department and taking legal action.

Once you believe that you have been treated wrongfully or unfairly by your insurance company, then you have the right to submit a complaint. Usually, you will have to file a complaint with your state’s insurance department. It is important to look up your state’s procedure by filing a complaint as they can vary. Usually, once you have filed a complaint, it may begin a long process in which you and your insurance company will work through a settlement. It’s important to understand each state may have different laws pertaining to health insurance and bad faith business practices. Also, each state may allow for different policyholder rights. So, it is important to look up these laws in your state to see if you can file for a complaint or more.

Another option you may take is filing a lawsuit against your insurance company. With the help of a qualified insurance lawyer, you may take your issue to court where you may fight to reverse the insurance company’s decision regarding your claim. Also, with a lawsuit, you may also receive damages if they have committed any actions in bad faith that have led you to suffer in any way. Not only may an insurance lawyer assist with a lawsuit, but they can also help to inform you of your rights as a policyholder and help you to determine if they have been violated in any way.

Finding an Experienced Health Insurance Denial Lawyer Near Me

Health insurance is just like any other business in that they have customers and make profits from their services. However, since the services they provide to their customers pertains to their health, they have special responsibilities and duties to follow when handling their business. Customers buy into health insurance policies with the expectation that insurance companies will be there when they need it the most and they will provide a safety net should anything occur them in the future. All insurance companies should treat you fairly and put your health ahead of making profits.

When purchasing a health insurance policy or filing a health insurance claim, it may be helpful to know what your insurance company is supposed to do for you. Not everyone knows what procedures are required and health insurance companies know this, and they can take advantage of you for their profit. If your insurance company has violated any of your rights as a policyholder, has taken advantage of you, or has wrongfully denied your health insurance claim, then you can get legal help. Stop Health Insurance Denials can provide you with the best legal assistance with insurance-related matters in the nation. Our employment attorneys are some of the most experienced throughout the nation. Contact our offices today at 310-695-5241. We are waiting to hear from you about your insurance claim denial. Call us today so we may begin reviewing your case.