Anyone who has ever filed an insurance claim knows how aggravating and time-consuming it can be, and even more so when dealing with an injury or illness. Merely reading and understanding your policy is a chore. You’re not sure what the clauses mean as the terms and definitions stated therein seem to contradict one another. It’s not your fault: insurance companies purposely write their policies in ambiguous language. Many are the times when a claim is denied and then the claimant is told to read the policy. In such instances, some individuals assume the insurance company knows better than they do and give up their pursuit altogether.
Get Insurance Appeal Help
Battling a health insurer when it refuses to pre-authorize treatment of pay your medical bills can be a pain. It can cause a great deal of financial worry, especially if you’re faced with a large medical bill. We know the stress and panic you feel but there’s light at the end of the medical debt tunnel. The unfortunate thing is that it’s not uncommon for insurance companies to deny coverage for certain treatments. But the fortunate part is that there are several strategies that you can apply to demand an insurer to reconsider the claim denial. A denial is not the end; it’s just the starting point. You have the right to appeal if the insurer still denies your claim even after an internal review. Appealing a health claim denial is not an easy process. It takes time and energy, which is even more detrimental when you or your loved one is sick.
A seasoned insurance denial attorney can assist you with this process. The attorneys at Stop Insurance Denial Law Firm can work to gather the full details of your medical situations, review your policy and applicable laws and regulations, and use the facts to develop a successful appeal. Instead of accepting a denial and going through financial turmoil, we can help guide you through the internal and external appeals process. We could also help you file a lawsuit to recover any out-of-pocket expenses that may have accumulated because your claim was denied.
How an Insurance Company Can Deny a Legitimate Claim
Insurance policies are contracts and both parties are expected to honor the terms of the policy when it comes to paying premiums (for the insured) and paying a claim (for the insurer). However, there are many strategies that insurance companies use to avoid payments that may be legitimate. The main source of conflict between insurers and policyholders is whether the treatment is considered medically necessary and is likely to result in an improvement of the policyholder’s health. Health insurers generally require that an insured prove the necessity of the medical treatment. This means that cosmetic procedures are not included and the same applies for an “off-label” use of a drug and many investigational or experimental treatments, or which are not recognized in medical literature and the outcomes are not definite.
As such, insurance carriers often review and deny coverage for a procedure, treatment, or service because they consider it not to be medically necessary. In addition to preventing you from receiving the treatment and care you need, there is also an issue of concern since many health insurers employ teams of individuals who are highly trained and skilled in looking for reasons to deny claims. No matter what type of insurance coverage you have, being denied benefits to pay for a diagnostic test, prescription, service, or procedure could be detrimental to your health.
Another method that health insurers use to deny claims is by stating that the acquired treatment took place out-of-network. Insurance companies have a network of doctors and hospitals with which they have an agreement, which guarantees that the insurer will pay for all approved treatment. When you take on a policy, it means that you agree to seek treatment from providers in the network. However, this can be unreasonable in some situations. For instance, if you’ve been injured while traveling or your condition gets critical and you have to be rushed to the nearest hospital, you may not be able to choose a provider, which means that you’ll have to seek out-of-network treatment. If such a case, you may argue on appeal that the need to get treatment was so dire and you had no other choice but to seek out-of-network treatment.
When you’ve fallen sick or have suffered an injury, you expect your insurer honor their promise and cover your medical treatment. insurance companies make profits by collecting premiums but then find ways to keep the money from going out of their pockets. This can include arguing that the policyholder had a pre-existing condition, the provider is out of network, or the medical care was not medically necessary. No matter the stated reason for a claim denial, policyholders have the right to appeal. An appeal can be filed with both the insurer and the state.
A credible insurance denial attorney can help policyholders navigate the process and get the coverage you need. At Stop Insurance Denial Law Firm, we have the skills and experience it takes to file a thorough, complete, and comprehensive appeal that will give you the best chance of getting the insurer to reconsider their decision. To make sure your appeal letter is successful, we’ll thoroughly evaluate your claim file, work with your doctors to get accurate and complete medical records, review your medical files, identify problems and mistakes you may have made when filing your claim, get experts to examine you, and issue reports showing that you’re entitled to coverage.
Now That My Claim Has Been Denied, What Do I Do?
Most of our clients come to us shortly after they’ve received a letter or telephone call notifying them that their claim for benefits or insurance pre-authorization request has been denied. Maybe your treating physician recommends a longer hospital stay or a certain medical procedure to improve your health, but your insurer refuses to pre-authorize coverage. Or maybe you already received treatment or under went a procedure, but now your insurer has refused to pay the large medical bills.
Whatever the case, just call Stop Insurance Denial Law Firm attorneys. We can help you in preparing the appeal letter that will convince the insurance company to reverse benefits denials. Since most individuals receive their insurance coverage through their employers, many of the claims are governed by ERISA (Employee Retirement Income Security Act), which governs employer-sponsored benefit and pension plans. There’s a wide range of procedural protections and requirements provided by ERISA and this includes a mandatory appeal procedure.
Stop Insurance Denial Law Firm can help you enforce your rights, which may include access to insurance contracts, plan policy, telephone logs, emails, reports, and other important documents showing how your insurer handled and determined your claim. We can review the claim file and plan booklet and help you prepare an effective appeal. We also help you understand your rights under your State’s law and other federal laws.
Appealing an Insurance Denial
Regardless of the reason given for your insurance denial, the appeals process is the same. As provided by the law, all insurance companies must state in writing the reason for denying benefits. There are also required to create room for an internal appeals process, which involves allowing the policyholder to file appeals within a minimum of 30 days. By law, insurance companies have a limited time explain their decision for the denial after you’ve submitted a claim. This means providing a written explanation of payment denial within 30 days for medical services you’ve already received and 15 days for a pre-authorization request.
While these laws are, to some extent, pro-consumer, it’s usually rare for the appeals to go through. This is owing to the fact that the appeal is handled by the same individual who denied the claim in the first place. This is why it is necessary to file an appeal with the help of an experienced attorney. Contact Stop Insurance Denial Law Firm today.
In most cases, the policyholder would be required to provide a written statement by their treating physician explaining why the denial was inappropriate. This means giving more details as to why they need the treatment, medication, procedure, or medical device in question. As such, it’s generally critical to collect medical evidence to support the medical necessity of the course of treatment.In addition to providing sufficient evidence to support an internal appeal, it’s also worth noting that you must file an appeal within 180 days of receiving a denial notice. However, the time limit allowed to formally file an internal appeal varies from one insurer to the other. So, check your plan carefully.
Writing the Appeal Letter
One of the biggest mistakes that can compromise your chances of getting the benefits you deserve is writing your own appeal letter asking your insurer to do a full and fair review of its decision. You need to hire an attorney who is experienced in writing appeals, working with doctors, and battling with insurance carriers in order to get you the coverage you need and deserve. From the day you file your claims, the insurer will be bringing together a claim file that constitutes of expert reports paid for by the insurer, medical reports, notes of conversations between you and your claims representative, and basically any other document completed by you and your physicians. Your insurance carrier can deny your claim even if the claim file is not complete. It’s upon you to ensure that all the documents are provided and there’s sufficient information proving that you’re entitled to benefits.
Remember that your insurer can bank on inaccurate, unrefuted information to deny your claim for health care benefits. Insurance companies are not mandated by the law to make sure that the claim is accurate and complete. This means that you bear that burden.
Hire an Attorney to Help Write Your Appeal Letter
There’s not a point in the claims process when it’s too early to hire a seasoned lawyer. But it’s highly critical to ensure that retain legal counsel immediately after the denial of your claim for benefits. Remember that you have 180 days to submit your appeals letter. Don’t be fooled when your insurer says that you can “request a review” of their decision and include more supporting documents that support your claim. This is not an informal process but a formal appeal required by federal law. So, instead of the federal government forming a board to evaluate and consider formal administrative appeals, the law places that right back into the hands of the insurer to decide whether or not your claim for health care benefits was correctly denied.
Once you file your formal appeal with your insurer, the record is locked. As such, no other information can be added should you need to prove your case in court. The records provided will serve as the evidentiary basis that the judge will use to determine whether or not the insurer should have paid your health care benefits. If your best evidence was never submitted to support your claim, chances are that the court will never see it. For this reason, it’s important that you seek the services of an attorney as soon as possible. The attorneys at Stop Insurance Denial Law Firm can help gather all relevant documentation, make sure that they’re accurate, and draft the appeals letter as it should be done. It’s important that you present the best evidence to the insurer as to why you need the health care benefits in order to maximize the chances that the insurer will cover the medical treatment.
Also important to note, it might be detrimental to file an appeal in circumstances where it’s not necessary. In addition, claimants should seek legal counsel to establish which state regulatory agency to file an appeal with. The outcomes of such appeals can significantly determine whether a lawsuit can proceed. In some cases, it’s more advantageous to file a lawsuit than going through an appeals process that may not be successful and may affect the claimant’s ability to get the benefits through a lawsuit.
Applying For an Independent External Medical Review
It’s not uncommon for health care insurance consumers to exhaust the internal appeal process as provided by their insurer, and still get an outright denial of payment or coverage. By law, policyholders have the right to have an independent external review performed by an independent review organization or another independent body. Because the external reviews are usually conducted by the State’s Insurance Department, you may feel that the process is more likely to achieve an independent and fair determination of your insurance benefits claim. A written request for an external review must be submitted by the claimant within 60 days of the date you receive a final decision from the insurance company.
The independent third party may decide to overturn or uphold the insurer’s original decision to deny claims. The final decision is binding at the external review level and this means that if the external reviewer reverses the insurer’s denial, the insurer is obligated by law to accept the decision and give you the payments of services indicated in the claim. We can advise you with regard to your rights under the federal and state laws.
Filing a Lawsuit with the Help of an Insurance Denial Appeals Attorney
While the internal appeals and external review process can lead to a change of decision made by the insurer, in some cases, filing a lawsuit after an unsuccessful appeals process is the only way to secure coverage. If you or your loved one has had an insurance claim denied, contact Stop Insurance Denial Law Firm attorneys today to determine what options may be suited to your circumstances. Your attorney can consult with experts, review all the policy language, and then advise you about your rights. If you wish to proceed with a lawsuit, we can file acomplaint to help attain the insurance coverage. In litigation, an attorney takes depositions of the insurance company employees dealing with the claim, obtains the written documents, and then evaluates the best trial strategy for proving a claim.
If the case involves insurance bad faith, the attorney can seek benefits of the insurance contract on behalf of the insurer. The lawyer can also file for additional damages that may have been incurred as a result of the insurer’s bad faith. This may include emotional distress damages, attorney’s fees, and potentially, punitive damages meant to punish wrongful insurance conduct and make them act appropriately in the future.
Finding Insurance Appeal Help Near Me
A denial of coverage for health care even when one has insurance can place a great burden and cause financial and emotional distress. If your insurance claim has been denied, that’s not the end of the road. You have the right to file an appeal with your insurer. An insurance denial appeals attorney could help. At Stop Insurance Denial Law Firm, we are committed to fighting for our clients and forcing health insurers to honor their policies and provide coverage under their policy. Stop Insurance Denial Law Firm is a nationally recognized law firm that helps clients all over the United States. You need an attorney with the experience and skills to explore your options and fight hard to collect the benefits rightfully due to you under your insurance policy.Contact us today at 310-878-1771 to schedule a free, initial consultation. Let us improve the chances of winning your case.