You’ve been faithfully paying your insurance premiums every time they are due. Suddenly, disaster strikes. You are involved in a car accident that causes serious upper back, shoulder, and neck pain that won’t fade away even with months of chiropractic or physiotherapy treatment. You develop an illness that saps not only your strength but also leaves you struggling to go about daily chores. You decide to fill out the disability claim forms and have your physician complete medical forms a confirmation that you aren’t capable of doing any work. Yet, even with a huge medical bill to your name, you receive a phone call from your insurer saying that your claim was denied.

Often insurers are for-profit businesses that usually try to pay out as little as possible in Insurance claims as a way of looking after their financial bottom line. This, in most cases, leads to the denial of valid insurance claims for treatments and procedures covered under the policy. The denial can result in financial devastation or prolonged suffering. insurance providers are often acting in bad faith when denying valid insurance claims. For this reason, it is imperative that you understand how to recognize the most common circumstance of insurance denial and the excuses that insurer’s give for denying valid insurance claims.

Treatment Not Considered Medically Necessary

In the insurance landscape, an all-too-common basis for denial of valid insurance claims is that the procedure, medical device, or treatment was not medically necessary. But the phrase “medical necessity” is a vague concept for various reasons. Treatment plans basically account for the person just as much as the diagnosis. This means that a certain type of treatment may be necessary for one or two individuals diagnosed with the same disease, but not for the other. Insurance companies struggle with defining medical necessity when it just does not fit a mold. Some insurers define medical necessity as a device or service that is:

  • Ordered by a doctor

  • Neither experimental or investigational in nature and is not provided for research purposes

  • Commonly recognized throughout the medical industry as the most suitable treatment of an injury or sickness

  • Not allocable to the patient’s vocational training or scholastic education in the case of hospital confinement

Conversely, other insurance companies consider treatment or care to be necessary when, in the insurer’s interpretation of accepted medical standards, it cannot be omitted without having a significant negative impact on the patient’s condition. Either way, regardless of whether your insurance policy generally or specifically defines medical necessity, the definition will be subject to diverse interpretation. This creates an opportunity for insurance companies to avoid potential liability since determining the necessity of a given treatment for one patient is a specific evaluation that generally does not apply to others with the same condition.

Usually, before giving a pre-authorization for a service or even paying a claim, most insurance companies will require a showing of medical necessity. As such, a claimant may be required to show the medical necessity of a procedure, treatment, or medical device. For instance, Anthem may require claimants to establish that prosthetic devices, organ transplants, back surgeries, or certain mental health treatments are medically necessary. But in most cases, insurance companies wrongly deny services even if the treating doctors have recommended the services as the most suitable form of treatment.

For instance, an insurance company may automatically deny a claim for laser hair removal because such treatment is considered cosmetic and therefore not medically necessary. But then, a claimant may suffer from a severe case of recurrent folliculitis, which is a condition where a person’s hair follicles become inflamed and develop into cysts that cause extreme pain. Hair laser removal is the medically accepted treatment for this condition. The insurance company may automatically deny the claim when the policyholder submits a claim for the treatment, wrongly assuming that the treatment is cosmetic. Put simply, the insurance company acts on assumptions and avoids learning the facts hoping that the claimant will give up their quest altogether. Without a skilled insurance denial attorney, many claimants will accept the decision made by their insurance company and pay the bills themselves, benefiting the insurer.

It’s also important to understand that insurance denial based on medical necessity is also affected by whether the policyholder has an ERISA (Employee Retirement Income Security Act) or non-ERISA insurance plan. Most policyholders fall under ERISA. Non-ERISA policyholders typically work for a government entity (e.g., police officer, firefighter, teacher, etc.) a church, or they privately purchased their insurance on their own.

In an investigation conducted by insurance regulators, a batch of insurance denials from Kaiser Permanente was reviewed and it was discovered that the overwhelming majority of the services denied were in fact medically necessary. The laws that apply to insurance and the criteria used to evaluate benefit or service requests are complicated. If your claim was denied because your claim was considered not medically necessary, consulting with an experienced insurance denial attorney is critical to your health or your loved one’s health.

Medical Treatment Was Out-Of-Network

It is true that not every medical cost is predictable. Disaster can strike any minute and a person may fall sick or be injured while traveling. When this occurs, he or she may be forced to look for emergency medical services while out of their insurer’s network. The fact the treatment was not offered by an in-network provider can be used by the insurer to refuse to pay for any treatment or to only provide coverage at a reduced amount, leaving the insured with huge medical bills that they’ll be required to pay out-of-pocket.

When’s Treatment Considered Out-of-Network?

All health insurers in the United States have a network of hospitals, doctors, and other healthcare providers. These are professionals with which the insurer has an established relationship and an agreement regarding payments for medical treatments. As such, insurers often deny coverage for certain medical treatments that are considered out-of-network. Under most Preferred Provider Organizations and nearly all Exclusive Provider Organizations and Health Maintenance Organizations, insurers deny treatment as out-of-network if it isn’t offered by an in-network healthcare provider. Insurance companies may require policyholders to get treatment from healthcare providers within their network depending on the type of their insurance plan. For this reason, the insurer may agree to pay at a reduced rate or even decline to pay if a subscriber seeks medical treatment from an out-of-network provider. This usually happens due to an emergency.

Also, a policyholder may deliberately choose to seek treatment from an out-of-network provider. For persons with rare health conditions, for instance, only a few physicians may provide services to such individuals. Because of this, a person can opt to go to an out-of-network provider in order to obtain the treatment they need. Either way, the insurer may decide to out rightly deny an insurance claim. In the United States, insurance companies are required by law to allow their members to go out-of-network for medical treatment if they can’t find the appropriate treatment within the insurer’s network.

Most health insurers provide their policyholders with a list of their in-network medical providers, usually through aprinted directory or the company’s website. However, the burden of locating in-network medical providers is squarely placed on the policyholder’s shoulders. Well, it may seem pretty easy and not much of a burden to go over the list and choose a provider, right? Not as you think. Many policyholders are baffled when they find out that the in-network health care providers listed for a certain type of care do not actually fit their healthcare needs. In other cases, the in-network providers listed by insurers are not trained for and do not specialize in the kind of services they’re listed for. Some may have been listed by the insurer but are no longer practicing in that area or are currently practicing in a setting that won’t suit your specific needs. Sometimes,the medical provider listed by the insurer is no longer networked with the carrier or the contact information has changed and not been updated.

However, there may be legal avenues through which a claimant can demand that the insurer covers out-of-network costs for necessary medical treatment. An out-of-network coverage attorney at Stop Insurance Denial Law Firm can help policyholders whose claims have been denied understand their legal options and choose the option that offers them the best chance of getting coverage for their treatment. Our attorneys are committed to working towards a positive outcome for you.

Investigational or Experimental Treatments

Medical science has significantly grown over the past fifty years. Doctors and health researchers continue to make groundbreaking advances that help people who were in the past without hope. For many individuals, especially those with rare diseases, these advances create new opportunities in providing treatment for their conditions. However, many health insurers are not cognizant of this fact and do not see things from the same angle. New clinical investigations or experimental trials are costly and not guaranteed to have a positive impact. For this reason, insurance companies usually hesitate to provide coverage for treatment and procedures that may or may not improve the health of a policyholder.

The concept behind insurance is a simple one. The policyholder agrees to pay monthly premiums and the insurance company pays for medical treatment that is necessary to improve a person’s quality of life or save their life. Where hang-ups usually occur is when a person has a disease or condition that was traditionally considered incurable or untreatable. While experimental or investigational treatments are usually carried out by licensed doctors, their results are basically unknown. Insurers are not in the business of taking risks with their money. If they’re not sure that a treatment is going to benefit an insured and improve their health, they usually deny coverage. It’s not always advisable to seek new methods of treatment if they are not fully established and approved.

The Legality of Investigational or Experimental Treatment Denial

The courts have rules that health insurers are well within their rights to deny benefits for investigational or experimental treatment. However, many policyholders are not able to understand what is covered under their policies because they are written in a vague and ambiguous manner. This lack of clarity has been the main cause of many different lawsuits that involve medical denials for experimental or investigational treatment. It can be even difficult to define the concept of treatment being experimental. When making a ruling, courts usually follow the United States 4th Circuit Court of Appeal method of determining of determining whether treatment is investigational or experimental as in the case of Martin v. Blue Cross and Blue Shield of Virginia. Courts should examine:

  • The available medical literature

  • The authorization given to the patient by the insurer

  • The protocol used by the doctors

  • The plain language of the policy

  • The number of patients who’ve already received the treatment

Medications and procedures that are considered experimental may be the only hope of recovery for some individuals. But since insurance companies are often hesitant to pay for such treatments, it becomes difficult for individuals to seek betterment in their lives. If your claim has been denied, an investigational or experimental treatment denials attorney could work with you to examine your medical needs, review the reasons your claim was denied, evaluate the case law involved in your situation, file an appeal, and bring a lawsuit against your insurer.

Pre-Existing Medical Conditions

Most health insurers place weighty emphasis on pre-existing medical conditions. When applying for an insurance plan, they always ask the applicant a variety of questions regarding prior illnesses and medical history. Some companies even go a step further by asking applicants to give recorded statements about their medical conditions to create a way to minimize or deny payments for medical expenses. If a policyholder falls ill or gets injured, they may argue that the symptoms are related to prior illnesses or injuries instead of the current conditions.

After all, insurance companies are businesses focused on making profits and looking after their financial bottom line. They, therefore, try to exclude individuals with pre-existing conditions or charge higher premiums to cover them. A pre-existing condition can be something like asthma, high blood pressure, diabetes, cancer, or allergies-just any health problem that can lead to other illnesses or cost the insurer more in claims expenses.

Insurance companies are charged with a duty of knowledge of information concerning a policyholder and are therefore expected to know if the policyholder has a pre-existing condition. Insurance companies should investigate the information disclosed by an applicant. For instance, if an applicant lists the name of a doctor who treated them for a certain health condition, the insurer is would have discovered that there was a pre-existing condition had they cared to investigate the doctors’ records.

Pre-Existing Conditions and the Affordable Care Act

The Patient Protection and Affordable Care Act eliminated the pre-existing conditions requirement that had been imposed by insurance companies. This means that health conditions can no longer be taken into consideration during the application. As provided by the act, children under the age of 19 with pre-existing conditions such as autism or allergies could not be denied coverage. Also, premiums can only be based on family size, zip code, age, and tobacco use. As such, an individual an individual already receiving cancer treatment will still pay the same premium as their healthy, same-age neighbor. But even with this, some insurance companies still deny treatment based on pre-existing conditions or failure to inform their insurer of the pre-existing condition.

A Policyholder’s Rights Following a Claim Denial

After an insurance claim has been denied, the claimant has the right to obtain all the necessary documents showing the circumstances of denial. They also have the right to receive a written letter from their insurer giving a clear explanation of the reasons for the denial,the guideline or criteria used the clinical reasons and evaluations, as well as information about the claimant’s right to appeal the denial. Policyholders also have rights to be advised of the insurance company’s obligations and of all provisions that apply to their claim.

Finding Insurance Denial Help Near Me

In your time of need, the last thing you want is having difficulties getting your claims paid and having to fight with a large insurance corporation. Your insurer understands that you’re in a debilitated state and don’t have the energy to fight back. You may also be overburdened by caring for your spouse. In addition, your children may not have the expertise to help with the situation. What’s more, the insurance policies are usually complicated and difficult to read and interpret.

If your insurance claim has been denied, we can help you fight the denial. Stop Insurance Denial Law Firm has for years been in the business of fighting for policyholders and their families to get the coverage they need and deserve. We fight to ensure that our clients are able to obtain treatment conditions and compensation for denied medical treatment. So, if your insurance claim has been delayed or denied, or your insurance company is not treating you fairly, the attorneys at Stop Insurance Denial Law Firm are always ready to help. Stop Insurance Denial Law Firm is a nationwide network of attorneys and we can connect you with an attorney no matter where you are in the U.S.

Call us today at 310-878-1771 or send us an email for a complimentary consultation and to get personalized legal advice on your case.