People expect that when they sign an insurance contract, pay their premiums, and sign the paperwork there will be coverage available. Insurance protection, whether it’s for health, auto, homeowner’s, or other types of insurance, is the safety net that people pay to protect them in case of a rare, but potentially expensive, risk. When an insurance company sends out a letter denying coverage for a claim that appears to be valid, it is no surprise that the insured person will be shocked. What coverage did they purchase if that wasn’t it? As the case progresses, an insurance denial attorney will be required.
Denial and its Impact
A denied claim with health insurance can have a significant impact. Even the most basic procedures can cost thousands of dollars. Costs of long-term care, especially for seniors, are often higher. Many people need insurance to help them manage these expenses and avoid losing their hard-earned money in a flash.
Getting Started
Understanding the decision is essential to any denial. Insurance providers usually send a standard letter that explains the claim in detail, along with the dollar amount and the reason for the denial. The reasoning behind this final part is not always obvious to the average person. It’s crucial to have your coverage policy on hand to compare what the insurance provider says as a reason for denial. It helps to clarify the communication.
In some cases, the provider may be merely trying to cut costs. Denying otherwise valid claims at home is a less ethical way to keep risk management costs low. People will not push the issue if they are denied. Insurance providers can save money by not paying cash. This tactic is not widely used, but certain providers on the discount end of the market use it to keep claim costs low. It is evident that, time and time again, a claim gets approved after it has been appealed.
Kaiser Foundation, for example, measures a number of statistics about health and access to health care. Four out of ten patients who appealed through the California Affordable Care Act won their appeals, and were approved for denied claims by simply asking. In 2021, only 17 percent of the claims were denied through the same coverage channel, but once again, a small share (specifically 0.2%) of those claims was appealed. Don’t accept “no” as an answer. Always appeal to get a second opinion. Formally, the filing is called an “internal appeal”.
Keep Good Records
While you are putting everything together to make the internal appeal and waiting for the response, take good notes on everything, including the reasons for your appeal. The file should include all appointments, communication from the doctor, insurance documentation, and policy information. You will need this later, if you want to appeal beyond the internal level. Your doctor will be able to help you in this case, by highlighting all the details of your medical condition, and filling in any gaps in missing records or what services were provided. It is a valuable tool when compared with the insurance provider’s documentation that outlines coverage for a paid policy. You’re catching them in their own words and commitments.
If your medical needs are urgent, you can request an expedited appeal.
An external appeal can result in bigger denials and larger steps.
A provider’s main defense is their bureaucracy. This is especially true in terms of the internal appeal process. By making the process so difficult, it is hoped that patients will simply drop the issue. The statistics cited above confirm this assumption. People often need immediate care. Waiting for a provider’s favorable decision is not an option.
When providers realize that a patient is serious about an appeal, they are more likely to listen. An insurance denial lawyer is the best way to convey this message. Representation can do much more than just tell a provider that a patient has legal representation. This also means the risk of a loss has increased.
California has had “bad faith denial” laws in place for many years. These laws, in essence, make the insurance company responsible for triple damages, if a patient wins a lawsuit. This can be a steep price to pay for denying an insurance provider coverage of a procedure which was initially much cheaper. Once counsel enters the picture, providers immediately shift their strategy in order to settle the case as quickly as possible. This is done to avoid prolonged matters. If the provider does not act, it could be liable for the costs of coverage, penalties and attorney fees.
California residents can appeal the decision of the insurance company and the dual denials by filing a lawsuit after exhausting the internal appeal. Although an attorney isn’t required, guidance from a lawyer can be very helpful. Many cases are settled at this stage because the providers do not want to go through with a formal lawsuit. Costs and risks for them continue to rise if they suffer a loss. Insurance companies tend to be resistant at this stage, hoping that the matter will never reach the external appeal phase.
The Lawsuit
Even if all administrative appeals have been exhausted, the process is not over. California patients can sue if they are denied coverage. This is an alternative to the above process and can be accessed by a licensed lawyer. The patient would benefit from working with an insurance denial lawyer who is experienced, as the nuances in both the procedural law (the filing of a lawsuit at a state court), and the merits (the actual argument), can be quite complex. The insurance provider is also represented by an attorney. With an Insurance Claim Denial Attorney on your side, you have a good chance of convincing the insurance provider to stop the fight and accept the best solution.
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