Health Insurance Lawyer

Medical and healthcare bills can pile up quickly and become a hindrance in getting a life-saving treatment for you or your loved one. That is when health insurance comes in. Healthcare insurance is an investment every individual makes to ensure they get the best treatment without worrying about funds. But there are chances you may get into a dispute with your insurance company. Disputes between consumers and healthcare insurance companies are becoming increasingly common. Insurance companies can deny medical coverage, experimental treatment, paying for medical bills, or refuse to pay for visits to specialists. In such circumstances, appealing against healthcare insurance is the best way to get the money you rightfully deserve. Hiring a health insurance attorney is the best way to deal with the problem and ensuring you or a loved one is not devoid of access to life-saving treatment.

Reasons Health Insurance Claims Can Be Denied

Healthcare insurance claims can be denied for the following reasons:

  • The insurance company lacks the information required to process your claim
  • You received a treatment that was not covered under the policy
  • You have reached a maximum limit of availing of insurance claims for a year and cannot use them again
  • You have pre-existing conditions that prevent you from receiving expenses for treatment of specific conditions
  •  If the provider puts the wrong code for the service on your claim

The best way to check the validity of a denial is to analyze your insurance policy thoroughly. If your claim has been denied due to something that is not mentioned in your policy, then your insurer may be acting in bad faith. In such cases, you can sue your insurer and demand getting your insurance, and even more if you can prove that the company acted in bad faith. To challenge the denial, you are required to file a health insurance claim appeal.

Understanding the Appeals Process

Appeals are a legal tool that enables you to request insurance companies reconsider their decision to deny your claim. The Affordable Care Act (ACA) laid down in the US constitution empowers you with the right to appeal against the claim denial and even get it reviewed by a third party. A typical appeals process has the following stages:

Internal Appeals

In most states, the process begins by requesting the insurance company to review their decision. This is done by filing an appeal with the company. Generally, the details of filing for an appeal can be found in the denial letter. You would have to fill a form provided by the company, or you may be required to write a letter to the company requesting them to review your claim once again. Along with the appeal, you are required to submit the best arguments to support your claim. This can include letters from the doctors treating you or articles supporting an experimental treatment for your condition. During this stage, the company assigns the responsibility of reviewing the claim to a person who was not initially involved in making the decision in the first place. If the claim is denied once again, you can appeal for a second review. In this stage, the insurance company must consult a healthcare professional who was not involved in the decision-making initially or during the first review. During the second internal review, you can be present while the decision is being made and bring a health insurance attorney.

External Review

If both your first and second appeals to your insurance company fail, you can demand an independent third party to review your claim without any bias. The independent third-party review entity works in collaboration with a doctor that specializes in the condition that is in question. If your claim is denied once again, you can then challenge the decision in court. Similarly, the insurance company is also given the privilege of challenging the decision.

Bad Faith Insurance Claim Denials and Lawsuits

Insurance is a contract that you sign with the company. The contract binds you to make your premium payments on time and obligates insurance companies to cover the medical expenses they commit to in the contract. If an insurance company is denying the claim wrongfully or unreasonably, they are breaching the contract. This means the insurance company is acting in bad faith. In this case, you may be entitled to receiving compensation that can be more than your medical and healthcare expenses. The following actions undertaken by an insurance company can be classified as bad faith:

  • Fabrication of evidence by the insurance company
  • Refusal to accept an evidence
  • Refusal to investigate a claim
  • Unreasonable delay in the investigation of a claim
  • Unreasonable adherence to minor administrative or bureaucratic requirements
  • Any other evidence that can prove the insurance company acted in bad faith

If you feel that your insurance company acted in bad faith and denied your claim that you rightfully deserved, you can sue them and hold them accountable for their actions.

Why Hire a Health Insurance Attorney?

Hiring a health insurance lawyer helps you in the following ways:

  • Filing appeals even to insurance companies can be arduous as it involves lots of paperwork and research. Besides this, there can be a timeline associated with filing for appeals. With a health insurance attorney by your side, you can rest assured that you do not miss out on any deadlines and file a convincing appeal to support your claim.
  • Health insurance laws are complex and vary from state to state. A health insurance attorney is well-versed with the state laws and can help you build a case against the insurance company.
  • Going toe to toe against insurance companies without legal representation is a big risk. Most insurance companies have strong legal representation and experience in fighting such cases and can bully you in court. A health insurance attorney works in your best interests and ensures you are protected and are provided with the compensation you deserve
  • Most health insurance attorneys work on a contingency fee basis. This means you do not have to pay them upfront. They only take a percentage of the compensation awarded to you. Besides this, many states allow you to recover attorney’s fees, punitive damages, and non-economic damages from the insurance company. Therefore, hiring a health insurance lawyer increases the probability of you receiving greater compensation.
  • An expert health insurance lawyer can help you evaluate your case and save you valuable time and resources.

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