Los Angeles Cancer Claim Denial Attorney
Page Contents:
- Seeking Justice for Cancer Patients in Pasadena & Claremont
- Types of Cancer Claim Denials We Handle
- Does Insurance Cover Cancer Treatment?
- What Out-of-Pocket Expenses Can I Expect During Cancer Treatment with Insurance Coverage?
- What Constitutes “Medical Necessity” for Cancer Claims?
- Why Was My Cancer Treatment Denied on the Grounds of Medical Necessity?
- Should I Appeal Denied Cancer Treatment Based on Medical Necessity?
- Types of Appeals for Denied Cancer Treatment Based on Medical Necessity
- Is Cancer a Preexisting Condition for Health Insurance?
- Can Insurance Companies Deny Cancer Coverage on the Grounds of a Preexisting Condition?
- How Much Is Cancer Treatment with Insurance?
- Importance of Securing Experienced Representation for Underpaid, Delayed, or Denied Cancer Claims
- Choose a Firm That Puts Your Health First
Seeking Justice for Cancer Patients in Pasadena & Claremont
From navigating strong emotions like grief and anger to undergoing lengthy and difficult treatments, receiving a cancer diagnosis is a life-altering reality for many Californians. At The Law Offices of Scott Glovsky, we understand that families affected by cancer have enough to worry about without insurance complications.
Unfortunately, cancer claim denials are all too common, robbing deserving patients of the quality care they need and deserve to lead healthy lives. This is where an experienced cancer claim denial lawyer can make all the difference. If you or a loved one was denied cancer treatment by an insurer in Los Angeles, put decades of experience on your side by choosing The Law Offices of Scott Glovsky.
With a background defending California’s top insurers and a reputation for holding profit-driven companies accountable, Attorney Scott Glovsky is uniquely equipped to represent your best interests in and out of the courtroom. If your insurer is refusing to pay for cancer treatment, we can fight tirelessly for the favorable outcome you deserve while you focus on healing.
If you were denied cancer treatment in LA, choose a firm with a winning track record against big insurance companies. Contact us online to request a free case evaluation.
Types of Cancer Claim Denials We Handle
The Law Offices of Scott Glovsky is passionate about pursuing justice for clients during life’s most challenging seasons. Since 1999, our attorney has represented clients seeking cancer treatment for various diagnoses, including:
Does Insurance Cover Cancer Treatment?
It depends. While insurers typically cover at least some costs of cancer treatment, many insurance companies won’t cover the full treatment or even deny treatments altogether, preventing patients from accessing affordable and quality care.
Even when an oncologist believes that a certain treatment is the patient’s best chance at regaining their health, insurers may still deny claims on the grounds of medical necessity or investigational or experimental treatments.
Because every situation is different, assessing the specific terms and benefits outlined in your insurance policy is important to determine what your insurer will and won’t cover. Our attorney can review your policy with a practiced legal eye and hold your insurer accountable for their legal and ethical obligations.
How Do Insurers Determine Which Types of Cancer Are Covered?
Unfortunately, the cost of cancer treatment is inextricably linked to survival rates. Research shows that cancer fatalities are 20% higher among patients living in poor U.S. counties compared to those in more affluent counties. Similarly, the mortality rates in poorer counties were 200% higher for cervical cancer and 40% higher for male lung and liver cancer.
The ability to pay for cancer treatment has a direct impact on whether a patient will survive cancer. This can put patients and providers in impossible positions while the insurer protects their bottom line. Claims involving expensive prescribed drugs are more likely to be denied under the “medical necessity” umbrella. However, you don’t have to accept your insurance company’s denial. Our lawyer can help you file an appeal to receive the coverage you deserve.
What Out-of-Pocket Expenses Can I Expect During Cancer Treatment with Insurance Coverage?
For most middle-class Americans, coming up with tens of thousands of dollars for unexpected medical burdens while also paying expensive monthly health insurance premiums is an impossibility. Even if your plan covers cancer treatment, you may still find yourself overwhelmed with co-pays and out-of-pocket maximums.
Most insurance plans require you to pay 20% of treatment costs until you meet the maximum out-of-pocket amount. The current out-of-pocket average is approximately $9,200 for individuals and $18,400 for families in the ACA marketplace. If you have private health insurance or insurance through your employer, your out-of-pocket maximum may be even higher.
What Constitutes “Medical Necessity” for Cancer Claims?
It’s reasonable to assume a treatment is medically necessary when recommended by an experienced oncologist, especially those from preeminent cancer institutions like USC Norris and Children’s Hospital of Los Angeles. Sadly, many health insurers still deny coverage in these circumstances on the grounds of “medical necessity.”
Generally, healthcare policies deem treatments to be medically necessary when they are safe and effective to treat a particular condition. However, insurance companies also rely on differing definitions, standards, and criteria in their decision-making. If you believe your cancer claim was unfairly denied as medically unnecessary, don’t hesitate to contact our firm for a free case evaluation.
How Do Insurance Companies Determine if Cancer Treatment Is Medically Necessary?
Government health insurers like Medicare, Medicaid, and Medi-Cal typically utilize national guidelines from the National Comprehensive Cancer Network (NCCN) and other third-party organizations to determine cancer coverage. However, private insurers like Blue Shield of California and Anthem Blue Cross are more likely to create their own. This can lead to overly restrictive policies that exclude fair and effective treatments.
California law prohibits insurers are prohibited from using policies that vary from the standard of care in oncology. If a health policy is overly restrictive in defining medical necessity, you have the right to fight for coverage in court.
Why Was My Cancer Treatment Denied on the Grounds of Medical Necessity?
The less money an insurance company pays for your treatments, the more profit it makes. All insurance policies include a coverage exclusion that limits coverage for “medically unnecessary” treatments. There are multiple reasons why an insurer may deny treatment on these grounds, including:
Reliance on Unqualified Reviewers
Relying on unqualified reviewers without medical expertise frequently leads to misapplied criteria and unjust denials of care. For example, allowing a nurse or pharmacist without any oncology experience to determine the medical necessity of chemotherapy treatment can lead to improper denials.
Lack of Training
State law requires insurance companies to conduct full, fair, and thorough investigations into the grounds for coverage before denying care. If reviewers aren’t trained to conduct lawful investigations, this can also result in unfairly denied claims.
Financial Incentive to Deny Care
Insurance companies may also deny cancer treatment due to financial incentives. For example, if a company uses a bonus system tied to corporate profit, a reviewer may be inclined to deny coverage for personal financial gain.
Mistaken Denial
In some cases, claims may be unfairly denied by mistake, whether it be lost paperwork, confusing similar claims, or overlooking key details in medical records. However, even honest mistakes can inflict harm on patients seeking timely care. If you believe your claim was denied due to an error, we can work diligently to get it approved so you can receive the care you need.
Should I Appeal Denied Cancer Treatment Based on Medical Necessity?
Deciding whether to appeal a denied cancer claim depends on the specific circumstances. A significant consideration to keep in mind is whether you have an ERISA policy. This federal law governs most insurance policies that employers provide to employees, but does not govern most health plans from private health insurers, such as Anthem Blue Cross or Blue Shield of California.
ERISA Health Plan
If you have an ERISA health plan or insurance policy, filing an appeal is extremely important. Failure to do so will forfeit your right to overturn the denial by seeking help from a judge. Consulting a trusted attorney is critical to filing your appeal correctly, on time, and with all the necessary information.
Non-ERISA Health Plan
If you have a non-ERISA health plan, there are various factors to consider before appealing. For example, if your claim was denied due to a lack of information, it may be worth filing an appeal with additional documentation. If the denial has caused you physical, emotional, or economic injury, you may have grounds to file a lawsuit and recover compensation. No matter your situation, our firm can help you advocate for a favorable outcome.
Types of Appeals for Denied Cancer Treatment Based on Medical Necessity
There are various paths to appealing a denied cancer treatment claim. One option is a peer-to-peer appeal. This occurs when your doctor consults a medical professional employed through the insurer about the denial. Another option is calling the insurance company directly to request an appeal. Alternatively, you or your doctor can send a letter with supporting documentation.
Finally, you can also submit a request for an Independent Medical Review (IMR) from the California Department of Managed Healthcare (DMHC). Keep in mind that this option is only available for denials based on medical necessity. If you decide to request an IMR, the DMHC will send your case to a third-party company to review the denial. However, there are serious issues to consider before proceeding with an IMR. Consulting a skilled lawyer is paramount to making informed choices for your health and well-being.
Is Cancer a Preexisting Condition for Health Insurance?
A “preexisting condition” refers to a medical illness or injury that is present prior to the start of a new health plan, such as kidney disease, diabetes, and other chronic conditions. If you were previously diagnosed with or treated for cancer, your health insurer might claim that your cancer is a preexisting condition to deny coverage. Attorney Glovsky is well-versed in these legal nuances to hold your insurer accountable.
Can Insurance Companies Deny Cancer Coverage on the Grounds of a Preexisting Condition?
In the majority of cases, insurers cannot deny cancer treatment on the grounds of a preexisting condition. Under the Affordable Care Act (ACA), health insurance companies are prohibited from charging more or refusing coverage due to preexisting conditions. Once enrolled, your insurer cannot deny coverage or increase rates based on your health. The only exception includes “grandfathered” individual health insurance policies purchased prior to March 23, 2010.
What to Do if Your Insurance Company Denies Cancer Coverage on the Grounds of a Preexisting Condition
Unless your health insurance policy specifically states that cancer treatment will not be covered because it’s a preexisting condition, denials for cancer treatment coverage typically fall under the “medical necessity” umbrella.
While it can be frustrating to have your claim unjustly denied, there are options to overturn these decisions. If your claim was denied on the grounds of medical necessity, our skilled attorney can help you file an internal appeal to overturn the policy and represent you in court if needed. Our goal is to pursue the best possible outcome with the least amount of stress possible.
What to Do if Your Insurance Charges You More by Claiming Your Cancer Is a Preexisting Condition
Under the ACA, an insurance company cannot charge higher premiums due to preexisting conditions, including cancer. If you think your insurance company is violating this federal law, don’t hesitate to contact Attorney Glovsky for a free case evaluation. Our firm can fight tirelessly to hold your insurer accountable for upholding their ethical and legal obligations under the law.
How Much Is Cancer Treatment with Insurance?
It can be stressful to consider the financial burdens of cancer treatment, especially while focusing on your health. Unfortunately, this isn’t an issue that patients and loved ones can ignore. The precise cost will depend on unique factors, including:
- Cancer type
- Treatment type
- Geographic area
- The duration of the treatment
Other factors include your specific health insurance coverage and whether you have supplemental insurance. Depending on your unique situation, you may also face additional expenses for travel, childcare, household help, assistive devices, counseling, and more. Many patients are unable to work while undergoing treatment due to severe side effects, making financial planning a significant source of stress for families.
The total cost of cancer treatment is more than four times higher than treatment for other common health conditions (approximately $150,000). However, the total out-of-pocket cost will depend on various factors, including deductibles, maximum out-of-pocket costs, and co-pays for specific treatments and providers. According to the U.S. Bureau of Labor Statistics, several of the most expensive cancer drugs cost as much or more per month than the average American makes in a year ($52,800).
Although chemotherapy is one of the most common cancer treatments, it can cost up to $12,000 per month. This means that a cancer patient undergoing four chemotherapy sessions per year can incur nearly $50,000 in costs annually. Even after paying health insurance premiums, deductibles, and co-pays, the patient may still be responsible for $10,000 or more for chemotherapy costs. For patients in rural areas, the total cost can be even higher due to travel, parking, and lodging expenses.
At The Law Offices of Scott Glovsky, we understand the immense physical, emotional, and financial costs come with a cancer diagnosis. Our firm is committed to providing compassionate counsel and advocating for the coverage you rightfully deserve. If you can’t afford cancer treatment because your insurer isn’t holding up their end of their bargain, put decades of experience on your side by calling our time-tested trial lawyer.
Importance of Securing Experienced Representation for Underpaid, Delayed, or Denied Cancer Claims
When an insurer denies a claim, the company must legally inform you why the claim was denied and how you can appeal the decision, including time limitations. Hiring a qualified lawyer is crucial to successfully filing appeals and navigating the intricacies of the legal process. An experienced advocate can protect your rights and help you make informed legal decisions that are in the best interests of your health and financial security.
If you feel your insurer should be covering more of your cancer treatment costs, contact The Law Offices of Scott Glovsky for a complimentary case evaluation. Every day, our firm fights for clients facing financial devastation because their insurer refuses to provide the coverage they need and deserve. From communicating with insurance representatives to appealing denials, you can trust us to fight for the future and quality of life you deserve.
Choose a Firm That Puts Your Health First
At The Law Offices of Scott Glovsky, we believe patients shouldn’t have to waste time and energy fighting with an evasive insurance company when they should be focusing on their health and future. If you’re facing cancer treatment claim denials, you need a strong and experienced attorney who never hesitates to stand up to large insurers.
This is where Attorney Scott Glovsky comes in. Our firm has a reputation for being relentlessly tough on major insurance companies while providing compassionate, client-centric representation to patients like you. As a nationally recognized advocate, our award-winning lawyer has a proven track record of results against big profit-driven corporations, giving you peace of mind that your case is in experienced hands.
When your health is on the line, don’t settle for less-than-experienced representation. Call (626) 323-8351 to schedule a free consultation with our LA attorney.
Meet Our Team
If Results Matter, Then Hire Us
Our Case Results
Relentlessly Tough, Relentlessly Personal
Scott began representing policyholders instead of insurance companies in 1999 and has consistently sought justice for his clients in ways other firms cannot. Scott is passionate about helping policyholders obtain treatments, coverage, and reimbursement from California insurance companies, including Aetna, Anthem Blue Cross, Blue Shield of California, Health Net, Kaiser Permanente UnitedHealthcare, and other companies providing insurance.
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$17.3 Million
On April 30, 2019, a 39-year-old father was fatally injured when his Kia Optima collided with a disabled Los Angeles County Metropolitan Authority (LACMTA) bus on the I-10 freeway's express lane.
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$14.9 Million
Cowart v. Anthem Blue Cross, et al. Anthem sued for misleading California individual plan members about the doctors in its networks for its ACA (“Obamacare”) plans in 2014.
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$10 Million
General areas addressed: health insurance; treatment and procedure coverage; physician recommendations; critical organ, brain, cancer or spinal cord issues; and out of network coverage issues.
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$9.29 Million
Arce v. Kaiser. Kaiser Permanente sued for denying ABA and speech therapy to children with Autism Spectrum Disorders.
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$8.5 Million
General areas addressed: health insurance; treatment and procedure coverage; physician recommendations; critical organ, brain, cancer or spinal cord issues; and outside of network coverage issues.
