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Advocating For Clients When Health Insurance Claims Get Denied

Experienced Health Insurance Attorneys

Health insurance protects policyholders from unexpected and devastating medical expenses.  The Patient Protection and Affordable Care Act has added some complexity to your health care choices, but it also has added many protections.  One such protection is that health insurers can no longer deny claims because they involve pre-existing conditions.

You expect your health insurance claims to be paid when you incur medical expenses, especially when your procedures are pre-approved.  However, insurance companies often improperly deny health insurance claims and break their promise to provide benefits.  The reason for this: Insurance companies have a financial incentive to collect premiums and pay out less in benefits by denying valid health insurance claims, which will increase their profits.

If your claim for medical treatment was denied, you must take action quickly.  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.  Insurance policies also may impose strict deadlines.  This is the case in which you need to consult with a health insurance claim denial attorney.  McKennon Law Group PC in Newport Beach, California, is experienced in handling health insurance coverage claims.  Our attorneys can help prepare your appeal and ensure that deadlines are met.

Reasons Why Health Insurance Claims Get Denied

Our experienced and effective attorneys can guide you through the process of getting your health insurance claim paid.  Health insurers deny claims for a variety of reasons, but the most common reasons are:

  • A certain medical device or treatment is deemed not “medically necessary,” despite your physician’s recommendations.
  • A medical procedure or treatment is determined to be “experimental or investigatory” and thus excluded under the policy.
  • A condition is characterized as an excluded “mental or nervous disorder.”
  • An expense is not considered “usual or customary” and is thus not payable.
  • The medical care was not “pre-authorized.”
  • A policy exclusion applies.

If the health insurance policy was purchased directly from the insurance company without employer involvement, your policy is governed by state law.  California law (as well as the law in many states) implies in every insurance contract the 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 it prohibits them from conduct that would unreasonably deprive policyholders of their benefits owed under the policy.  Insurers who unreasonably withhold benefits or delay payments may be acting in “bad faith.”  

If an insurance company denies your health insurance claim in bad faith, you may sue for benefits due under the policy, “consequential damages” (damages that are caused by the bad faith conduct), emotional distress damages, punitive damages, attorneys’ fees and interest on past-due benefits (typically at the legal rate of 10%).  If your health insurance policy was obtained on a group basis through an employer, the group policy will likely be governed by the Employee Retirement Income Security Act of 1974, known as ERISA, 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.

Our attorneys may be able to help you recover your medical benefits if your health insurer unreasonably denies your claim for medical coverage.  We have seen many insurance companies avoid paying health insurance claims by issuing improper coverage denials in bad faith.  Because of our aggressive advocacy and regional and national reputation as a leading health, life and disability insurance litigation law firm, we can achieve maximum settlements and judgments/verdicts at trial. For more information, please see our Health Insurance FAQs.

Let Us Guide You and Get Results

If your claims for health insurance have been denied, McKennon Law Group PC may be able to help you.  We are a group of skilled, respected and aggressive attorneys who have represented hundreds of clients throughout California and nationwide.  For a free initial consultation, please fill out this free consultation form or call us at 1-800-682-4137.