With the skyrocketing cost of health care, you make sure that you pay your monthly insurance premiums so you’ll be able to pay for the services you or your children need if they fall ill or are injured and require medical care. You expect that your insurance plan will come in handy and cover the medical costs that you were promised will be covered, but your insurer out rightly denies coverage for a legitimate claim. Fighting a disease, being injured or going through the death of a loved one is already bad enough. And being left with a lot of medical bills can be overwhelming. For many, things could get more depressing when they received a letter notifying them that their claim has been denied. The insurance company is supposed to be on your side and pay out the insurance benefits that you’re entitled to, but there are instances when they will make things harder for you.

Insurance companies are in the business to make money and will deny legitimate claims just look after their bottom line. It can feel daunting to go up against insurance giants who seem to view you merely as a policy number. At Stop Insurance Denial Law Firm, we are committed to fighting for the rights of our clients from across the United States and hold insurance companies liable for covering legitimate claims that are covered under the insured’s policy. Our attorneys are thoroughly familiar with insurance law, contracts, and disputes. We’re skilled negotiators and always ready to take on the challenge of facing massive insurance corporations and forcing them to uphold their part of the contract. To learn more insurance appeals and/or schedule a free consultation with one of our attorneys, please call us at 310-878-1771 or fill out our online contact form.

What is an Insurance Denial?

An insurance claim denial is when your health insurer informs you that it will not cater for the cost of your treatment or medication. It can be exasperating and even scary if you’re unable to continue treatment, fill a prescription, or are left with huge medical bills. The fortunate part is that policyholders have a right to appeal the decision of their insurance company. While it can be a taxing process to deal with your insurance, many insurance denials may be resolved via the internal appeals process.

Common Disputes with Insurance Companies

Insurance disputes are growing more common and with constant changes in the health care landscape, they are set to increase more. Common examples of insurance disputes include:

  • Inaccurate charges for services

  • Wrongfully denied claims for coverage

  • Refusal to cover care for mental conditions and innovative treatment options

  • Denial of coverage for a medically necessary medical procedure of hospitalization

Common Reasons for an Insurance Denial

  • The doctor you saw was out-of-network

  • There was paperwork or data entry errors on the insurance policy number or benefits claim

  • The treatment or medication is required but you did not have aprior-authorization

  • You’re no longer enrolled with the insurance company or your coverage has lapsed

  • The treatment or services were not medically necessary

  • The treatment or procedure was experimental or investigational

Understanding What an Appeal is

Filing an appeal means that you’re asking your health insurer to reexamine its decision to deny benefits for a treatment, medication or medical procedure. The most compelling reason for pursuing an internal appeal is the potential of having it approved and getting reimbursed. Even so, appealing an insurance denial can be a daunting undertaking. But a knowledgeable and skilled insurance denial attorney can help you understand your legal options and how to best navigate the appeals process. There are some elements of the appeals process that are common across all health plans, which can be found in your policy document.

The appeals process has three distinct levels:

  • First-level appeal

    When you have a dispute with your insurer, the first step might be to try to resolve the issue on your own. This involves you calling your insurer and requesting that they reconsider the denial. Ensure you understand what your policy covers and verify that the service or treatment you want to receive or have already received meets the insurance guidelines and is covered under the plan. Point out the places in your policy that the denial seems to conflict with and your claim was wrongfully denied.

  • Second-level appeal

    If your insurer continues to uphold its decision to deny your claim after you’ve appealed it over the phone, you can now write to them and submit all the necessary records to support your claim. You may want to contact a seasoned health care insurance attorney from Stop Insurance Denial Law Firm who will aggressively advocate for your case.

  • Independent External Review

    This step involves having an external, independent evaluate your insurer’s denial and your appeal documents in order to determine if the insurance company was “right” in denying coverage. This step is usually taken if an internal appeal is unsuccessful.

How to Appeal When Your Insurance Claim is Denied

If your insurance company isn’t willing to settle your medical bill or pre-authorize treatment, you are most likely unsatisfied and distressed. Your health insurer shouldn’t have the final say. With the help of a seasoned insurance denial attorney, you may be able to get your insurer to reverse its decision. Here’s what to do with an insurance claim denial.

  • Understand what type of insurance you have

    It’s important to know your rights before you seek to enforce them. If you have a health care plan from a third party, chances are that you obtain the coverage from a managed care plan provider, an insurance company, a self-insured association, or the government. Checking your enrollment form is the easiest way to determine the type of plan or policy you entered into. This is a document that individuals sign as a way of asserting their desire to take part in the benefits of a policy

  • Know your coverage

    Insurance is a contract between the insurance company and the policyholder. All insurance policies have a member contract known as Evidence of Coverage that describes healthcare benefits covered under the plan. Review your documents and ask your insurer for a list of your benefits. Some states have laws related to the Patient Protection and Affordable Care Act (PPACA) that describes minimum benefits. For instance, a plan may be required to include essential health benefits

  • Some benefits may not be explicit in your policy

    More often than not, health insurers and managed health plan providers will deny coverage for benefits that policyholders are entitled to and hope that they are too ignorant to read their policy or take time to understand their rights. This usually occurs in cases where a policyholder seeks treatments for special needs (such as Autism Spectrum Disorders) and mental health. While certain autism treatments aren’t explicit in an insurance policy, they may be required under the law. It can be quite confusing and tricky to understand which treatments are covered under the plan, and it’s therefore important to check with an experienced insurance denials attorney that fights for the services or treatment you’re seeking.

  • Collect all necessary information and documents pertaining to your treatment denial.

    When filing an appeal, you want to include all the necessary supporting documents. Also be prepared to be on the phone a lot. Be ready to share your insurance information in each interaction.Always have ready the claim number as well as the date and number of the doctor who provided the service. Document all communications that you’ve had with the insurer and have all the information organized and easily accessible. Collect copies of lettersthat you receive from your insurer and all the letters that you sent to the insurer.

    If you had any phone conversations with the insurance provider, ensure that you keep a log of the date and time the conversation took place, title, name, or employee identification number of the individuals you conversed with. Be sure to include a detailed description of all that was said during the call. Also, it’s important to gather as much medical evidence concerning the treatment or procedure you receive or your needs for the treatment at issue as possible. This means getting all referrals from your health care provider as well as copies of your medical records. Your insurance company must commit their position and reasoning in writing and it's therefore paramount that you learn the complete basis for the denial of your claim.

  • Work with an attorney

    You can request the help of an insurance appeals attorney who can help you write an appeal letter and submit it to your insurer. An attorney can work with your physician to ensure that all the necessary documents are sent to the insurer. This may include a letter of support from your doctor with notes on how you’ve responded to the medication or treatment, medical reasons the treatment should be approved, test results related to the requested service, and clinical guideline or peer-reviewed articles that support the recommended treatment.

    Persistency is paramount when it comes to appealing your insurer’s decision and many times patients who are initially denied coverage end up getting approved and receiving the amount needed.

Internal Appeals Process

Insurance companies and managed health plan providers are mandated by law to have internal appeals processes. But before you start familiarizing yourself with your insurer’s appeal process, we highly recommend that you contact an experienced attorney who understands the ins and outs of health care coverage issues. An attorney will help you understand how the internal appeal process works and can advise you on how to best structure your appeal in order to get the results that you deserve. Every insurance company has a distinct internal appeal process, and you need to determine what your insurer’s process is. Some plans require policyholders to file more than one internal appeal before they request an independent review.

If you decide to appeal the denial decision, you must be prepared to adhere to their appeals process. When writing an appeal letter there are a few important things that should not be omitted, this includes; your name, contact information such as phone number and address, and information concerning your policy including the claim number, policy number, and the group number. Furthermore, you need to include as much written evidence as possible. This can include information such as medical records and a letter from your physician but always keep a copy of any document you send to your insurer.

Also, collect enough evidence from doctors and other health care providers stating why the treatment is medically necessaryand why the denial by your insurer is inappropriate. It’s worth noting that insurance companies have time limits for their internal appeal procedure. So, once you receive a letter indicating that your claim has been denied, you should immediately look into the time limits so you can know how much time you have before the internal appeals window shuts. Missing the deadline is immediate grounds for the denial of your appeals and can result in a loss of the opportunity to have the denial appealed at all. Thisdepends on the regulations of your specific coverage so be sure to check your plan carefully. But typically, policyholders have up to 180 days or 6 months after receiving a denial notice to file an internal appeal.

External Appeals Process

After the internal appeal process, your insurer may decide to reverse their earlier denial and provide you with the coverage you need. However, if the insurance company decides to uphold its decision to deny your claim, you often have a right to have your claim reviewed by an independent third party through what is called an external review. An external review can be helpful in getting your insurance denial reversed but it is not a move that you should automatically make since it’s often not a precondition for seeking the court’s intervention because of a bad faith denial.

In some cases, it can be beneficial and more efficient for an individual whose insurance claim has been denied to skip the external review process and just file a lawsuit to obtain the coverage they need and deserve. For this reason, it’s important to consult with an insurance denial attorney if you have completed the internal appeal process and your insurer still upheld their denial decision. An attorney who specializes in bad faith insurance denials can advise you as to whether an external review is the right option to get coverage. If after speaking with a lawyer, you decide that seeking an external review is the best option, then you must determine the appropriate entity from which you should request for a review. If you’re covered by an insurance company, you will seek a review from your state’s Department of Insurance. Conversely, if you’re a member of a managed health care plan, you can request an external review from the Department of Health

Taking the Case to Court

If the external review process does not lead to the reversal of the denial or you decide to skip the external review stage, you’re left with the choice of filing a lawsuit against your insurer. When you initiate legalaction, your insurance company may pay a lot more attention even if it had ignored you in the past. In addition, you can obtain a complete coverage for the medical treatment you’re seeking, on top of the likelihood of additional monetary awards as a result of your insurance company’s bad faith in denying your coverage claim. At Stop Insurance Denial Law Firm, we take such cases on a contingency basis and this means that we don’t get paid but we instead take a percentage of the recovery. No pay unless we win.

Important to note: Chances are that your plan is covered under the Retirement Income Security Act (ERISA) if your plan is provided by your private company employer, meaning that your plan is not governed by state laws. You can only deal with your insurer on a federal level and as such, you are extremely limited on the steps that you can take.

Finding Insurance Denial Appeal Help Near Me

With years of experience serving clients across the nation, the attorneys at Stop Insurance Denial Law Firms are prepared to fight for your rights when you’re forced to go up against large and resourceful insurance companies in a legal dispute. At Stop Insurance Denial Law Firm, our attorneys know how to dispute tactics used by insurance companies and will fight for all the proceeds provided in your policy. We have the resources and skills to conduct thorough investigations to determine the extent of coverage you seek and get all the necessary supporting documents to prove your case.

Whether your benefit claim is governed by state law or by the federal laws of ERISA, we’re qualified and equipped to serve as your advocate, and we’ll so with so much passion and vigor. You can be confident in our ability to capably represent you and pursue your coverage. We’ll guide you through every step of the appeals process, making sure that everything is done as required by law and that all documents are properly sent to your insurer.

Whether you claim has been denied or delayed, we take on the legal challenge and get results while you focus on your health. Do not hesitate to contact Stop Insurance Denial Law Firm online or by phone at 310-878-1771 for a free consultation.