Health Insurance Claims
The American health care system relies heavily on health insurance. The first question you are asked when you contact a doctor’s office for an appointment is typically “What insurance do you have?” Whether your health insurance is part of a benefit package offered by your employer or you purchased it through the marketplace, you rely on your health insurance provider to help cover the often high cost of health care services. After all, that’s the point of paying for health insurance. When a health insurance company unreasonably delays or denies the payment of claims, acts in bad faith or engages in unfair trade practices, or commits fraud, you may be able to file a legal claim against the insurance company. If your claim is successful, you may be entitled to monetary damages for the harm you have suffered.
Understanding Your Health Insurance Policy
Few people actually read the fine print hidden in the policy documents when they purchase health insurance. In fact, most people only see a general “summary of benefits” before they agree to a health insurance plan. When you purchase a health insurance policy, however, that policy becomes a legally binding contract between you and the health insurance company. As part of that contract, the insurance company has a legal obligation to abide by the terms of the contract as well as to act in good faith and avoid unfair trade practices. Health insurance companies, however, are also in the business of making a profit which can provide an incentive to avoid paying valid claims when possible. It can even push a company to commit what amounts to fraud in an effort to entice members of the public to purchase a health insurance policy.
Delayed Approval or Denial
One way your health insurance company might breach the contract it has with you is to delay paying a claim or delay approving/denying a claim. For an insured, delayed payments often result in collection efforts by providers. Even worse, a delayed approval can mean the difference between life and death, improving or worthening the insured’s health condition, and in many cases to the following injuries:
- Delayed Injuries
- Traumatic Brain or Head Injury
- Spinal Cord Injury or Paralysis
- Serious Back or Neck Injury
- Fractured or Broken Bones
- Scarring or Disfigurement
- Amputation or Dismemberment
- Birth Injury
- Wrongful Death
- Class Action Lawsuits
For the most part, the insurance industry is governed by state law. In California, an insurance company must respond to a claim for benefits within 15 days and must approve or deny the claim within 40 days. Moreover, it is considered an unfair trade practice for an insurer to fail to act “reasonably promptly” when processing or settling a claim. If an insurer has acted in bad faith, breached its contract with you, or engaged in unfair trade practices, you may be entitled to pursue a legal claim against the insurer for monetary damages.
Without the help of a qualified professional, the world of health insurance claims can seem overwhelming and unnecessarily confusing. With co-pays, deductibles, co-insurance, out-of-pocket limits, in-network providers, out-of-network policy exclusions, and confusing formulary lists for prescription drug coverage, it is often a challenge just to understand policy basics – let alone interpret “explanation of benefits” statements or the reasoning behind claim denials. Health insurance claims attorneys understand state and federal health insurance laws and offer help navigating insurance policy and claims complexities.
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Reimbursement Claims and Appeals
When you choose an “in-network” provider for your medical care, the provider usually handles the initial insurance claim on your behalf. However, when choosing a provider who is outside the policy’s network, you may be expected to pay for services received and file a claim with your insurer for reimbursement. If your submission is deemed “not in good order” by the insurance company, they could deny the claim initially, adding unnecessary delays to an already frustrating process.
As a general rule, insurance companies can, after investigating claims in good faith, deny submitted claims – whether you used an in-network or out-of-network provider. Health insurance policies include provisions for appeals, giving policyholders an option to have denied claims reviewed again by an appellate panel at the insurance company. If your health insurance claim for a medical visit, test, or treatment was denied, the insurance company must provide an explanation stating why they are not paying the claim as requested.
A health insurance claims attorney can review requirements and paperwork associated with your claim or appeal, offering guidance and helping to obtain and organize additional documentation, as applicable.
Insurance Bad Faith Claims and Litigation
Unfortunately, for-profit insurance companies are sometimes motivated to conduct only cursory reviews of health insurance claims or to unreasonably delay or deny coverage or legitimate claims. In some cases, pre-approval for surgeries or procedures is revoked. In other situations, insurers deny benefits on the basis that the treatment prescribed by the claimant’s doctor was experimental or medically unnecessary.
If you believe your health insurance company acted in bad faith by denying your application for coverage, delaying or denying your claim, or refusing to pay the amount you believe was owed under the policy’s schedule of benefits, you may have a claim under either California’s bad faith insurance laws and/or under the Employee Retirement Income Security Act (ERISA).
Fraudulent Practices
While many insurance companies employ subtle tactics aimed at delaying or denying claims, some companies engage in outright fraudulent practices. Many companies sell “junk” health insurance policies – even though they have been forced to revise their terms and policies with the passage of the PPACA (Patient Protection and Affordable Care Act). An individual may purchase the policy under the belief that it will provide major medical or comprehensive coverage, only to find out the hard way that the exclusions and exceptions hidden within the policy make it virtually worthless. There are few things worse than finding yourself (or a loved one) in need of life saving medical treatment that you thought was covered by your health insurance policy and being told your claim for benefits has been denied partially or in its entirety. The good news is that state and federal laws may protect a policyholder who has been victimized by one of these “junk” policies.
If you believe an insurance company marketed its policies inaccurately or otherwise misrepresented the benefits available to policyholders, you may have a health insurance fraud claim.
Consultation with a Health Insurance Claims Attorney
Attorneys who represent policyholders in matters related to health insurance claims are well-versed in the language and procedures used by big health insurance companies, and are not afraid to stand up to protect policyholders’ rights. If your application for coverage or benefits claim was denied, it may be time to consult with a health insurance claims attorney to determine the most appropriate next steps you can take.
