Health Insurance Claims
Health insurance protects policyholders from unexpected and potentially devastating medical expenses. You may have a Preferred Provider Organization (PPO) policy, an Exclusive Provider Organization (EPO) policy or a Health Maintenance Organization (HMO) policy, among others. The Patient Protection and Affordable Care Act has added some complexity to your health care choices, but also has added numerous protections. One such protection is that health insurers can no longer deny claims because they are pre-existing conditions.
You expect your health insurance claims to be paid when you incur medical expenses, especially when they are pre-approved. However, insurance companies often improperly deny health insurance claims and break their promise to provide you the benefits you thought you had secured. This results because insurance companies have a financial incentive to collect premiums and pay out less in benefits by denying valid health insurance claims, thereby increasing their profits. This conflict of interest can motivate insurance companies to improperly deny your claim for health insurance coverage or reimbursement.
Health Insurance Bad Faith Claims Denials
Health insurers deny claims for a variety of reasons, but the most common health claim denials are for the following reasons: a certain medical device or treatment is not “medically necessary” despite your physician’s recommendations, a medical procedure or treatment is “experimental or investigatory” and thus excluded under the policy, a condition is characterized as an excluded “mental or nervous disorder,” an expense is not “usual or customary” and thus not payable, or the medical care was not “pre-authorized.”
If your claim for medical treatment was denied, you will need to take action. This may be an appeal or “grievance” procedure filed with your health insurer for its reconsideration or it may be a claim that is subject to an independent medical review by an independent medical review organization. In order to challenge the health claim denial, you may need to review your policy and/or the explanation of the denial to determine the insurance company’s appeal or grievance process. To further complicate matters, insurance policies may impose strict deadlines. You should consult with a health insurance claim denial attorney experienced in handling health insurance coverage claims as he or she can help prepare your appeal and ensure all deadlines are met.
Recovery and Damages for Health Insurance Bad Faith Claims Denials
If the health insurance policy was purchased directly from the insurance company without employer involvement, your policy is governed by state law. California law implies in every insurance contract the implied covenant of good faith and fair dealing, based on fundamental principles of fairness. This duty requires insurance companies act in a fair and reasonable manner, and prohibits them from conduct that would unreasonably deprive policyholders of their benefits owed under the policy. Insurance companies that unreasonably withhold benefits or delay payments are said to be acting in “bad faith.” If an insurance company denies your insurance claim in bad faith, you may sue for policy benefits due under the policy, “consequential damages” that are caused by the bad faith conduct, emotional distress, punitive damages, attorneys’ fees and interest on past-due benefits (typically at the legal rate of 10%).
For more information, please see our Insurance Bad Faith FAQs.
Recovery and Damages for ERISA Health Insurance Claims Denials
If your health insurance policy was obtained on a group basis through an employer, the policy will likely be governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 USC § 1001 et seq., in which case you can sue for policy benefits, attorneys’ fees and interest due on the unpaid benefits. Insurance bad faith damages are not available with respect to these types of policies. If your claim was made under an employee-sponsored plan, you can bring a legal action to recover your benefits and enforce your rights under ERISA. 29 USC § 1132(a)(1)(B).
For more information, please see our ERISA FAQs.
Health Insurance ERISA and Bad Faith Claims Denial Experience
McKennon Law Group specializes in helping you recover your medical benefits if your health insurer unreasonably and without proper cause denies your claim for medical coverage. We have seen many insurance companies act in their own financial interest and avoid paying claims by issuing improper coverage denials in bad faith. Because of our aggressive advocacy and our regional and national reputation as a leading health, life and disability insurance litigation law firm, we are able to achieve maximum settlements and judgments/verdicts at trial.
We have been litigating ERISA insurance, disability insurance, life insurance, health insurance, bad faith and other insurance matters since 1986. Our attorneys are nationally recognized experts in insurance bad faith litigation and have chaired numerous seminars and written numerous articles dealing with insurance bad faith claim issues. Our attorneys are top rated by all major peer review rating agencies and have been honored to receive numerous prestigious recognitions. No attorneys in California or anywhere in the United States are better suited to litigate your bad faith or ERISA health, life or disability insurance claims. In fact, the attorneys of the McKennon Law Group previously represented the insurance companies that denied such claims and thus have the broadest possible experience in litigating these types of insurance disputes. We can and will aggressively litigate your case to achieve maximum success. We have significant trial experience and we are not afraid to go to trial against the big insurance companies.
Contact us to schedule a free initial consultation regarding your insurance claim or litigation matter.
For more information, see our Health Insurance FAQs.