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FAQs for Insurance Bad Faith and Health Insurance Denials

Insurance and Healthcare Denials
FAQs for Insurance Bad Faith and Health Insurance Denials

What is insurance bad faith? In California, every insurance policy has its written terms. However, the law also determines that each policy also has implied terms. Such terms require the insurer to act in good faith and fair dealing to allow its insureds the benefits of the policy. In practice, this means an insurer must not act unreasonably or in “bad faith” when approving or denying coverage. What happens if an insurer denies coverage and its investigation into the coverage request or its determination was unreasonable? The insurer can be responsible for extra contractual damages such as emotional distress and even potentially punitive damages.

The following FAQs are for insurance bad faith and health insurance denials. Questions include the following:

    1. When should I talk to a lawyer about a health insurance denial? 
    2. Can a lawyer help get health insurance authorization?  
    3. Can I sue a health insurance company for denying my claim?  
    4. How much time do I have to sue my health insurance company for a denial?  
    5. How do I fight health insurance companies when they deny coverage? 
    6. Can an attorney help me if my medical bills are denied by an insurance company?    
    7. Can I win a dispute with my health insurance company?  
    8. How do I appeal a health insurance denial?  
    9. What can I do if I lose a health insurance appeal? 
    10. What do I do to get quick approval from my insurance company for cancer treatment/emergency treatment/urgent surgery? 
    11. What do I do if my insurance company will not pay for expensive medication? 
    12. What is a healthcare attorney?
    13. What is a health insurance attorney or a bad faith attorney? 
    14. Am I more likely to get denied if my plan is an HMO vs. a PPO? 
    15. What can I do if I win an appeal with the DMHC but my insurance company still will not approve a treatment?  
    16. What types of insurance disputes does your firm handle? 
    17. What damages can be recovered in a bad faith case? 
    18. What are an insurance company’s duties to its insureds in California?

When should I talk to a lawyer about a health insurance denial?

You should contact an insurance bad faith denial lawyer as soon as you receive a denial letter from a health insurance company. This is true even if litigation is not necessary or the right option for you. A lawyer who specializes in insurance denials can provide you with information about next steps and deadlines. He or she will also provide general guidance to maximize your chances of overturning the denial. Since there are several possible steps, it is important to act quickly. Some appeals must occur within a certain time period. And it can take time to gather the information necessary to make a sufficient appeal.

Can a lawyer help get health insurance authorization?

Yes. A health insurance lawyer can help guide you through the authorization request process. If the health insurance company denies your request, then a lawyer can help you decide what next steps to take. The lawyer can help guide you through an appeal or ultimately file a lawsuit against the insurer for a wrongful denial.

Can I sue a health insurance company for denying my claim?

The ability to sue your insurer for denying a claim depends upon your particular policy. If you have a group plan like one offered by an employer, then in most cases a federal law governs the insurance. In that case, the federal law ERISA requires that you go through certain steps before filing a lawsuit. This includes submitting an appeal to the insurance company. It’s different if you have an individual plan like one bought directly from an insurer or from a state exchange. With an individual plan, you can file a lawsuit as soon as you get a denial letter.

Whether you should sue though is a very different question. For an answer, you should consult with a bad faith insurance attorney as soon as you receive a denial.

How much time do I have to sue my health insurance company for a denial?

The time period you have to sue an insurer for a denial of coverage depends on your specific insurance plan. If you have a group plan such as one offered by an employer, then in most cases a federal law governs the insurance. In that case, the federal law ERISA requires that you go through certain steps before filing a lawsuit. Generally, you have two years from the date of denial to challenge an ERISA denial.

If you have an individual plan, then the deadline to sue depends on the claims that you intend to bring. It also depends on the law in your state. In California, you generally have two years to file a lawsuit for bad faith by the insurance company. You generally have four years to bring a claim based on the breach of the written contract.

These deadlines are important. As such, you should talk with a health insurance lawyer as soon as you receive a denial to help you determine what deadlines apply.

How do I fight health insurance companies when they deny coverage?

If a health insurer in California denies you benefits, then you have several options to fight that denial. These options include submitting an appeal to the insurer, filing a complaint with a state regulator, and filing a lawsuit. Which of these options is appropriate depends upon the specific facts of your circumstance. You should contact a bad faith insurance attorney as soon as you receive a denial to discuss your options.

Can an attorney help me if my medical bills are denied by an insurance company?

A lawyer cannot make your medical bills disappear, but can help you push your insurance company to pay for bills. A lawyer can help you decide between numerous options to fight the denial. These include submitting an appeal directly to the insurer, filing a complaint with a state regulator, and filing a lawsuit. An attorney can also, in certain cases, help you negotiate the medical bills to reduce the amount that you owe. Which of these options is appropriate depends upon the specific facts of your circumstance. You should contact a bad faith insurance attorney as soon as you receive a denial to discuss your options.

Can I win a dispute with my health insurance company?

Yes. Even though it might feel daunting and take time, it is possible to fight and beat your health insurer. You have a number of different options and different approaches to fighting a health insurer. To determine the best approach for your situation and to help you fight, you should contact a health insurance attorney who has experience fighting and beating insurers.

How do I appeal a health insurance denial?

To initiate an appeal, most insurers require that you or your healthcare provider either call or write to request one. But before you appeal, learn about the appeal process of your specific insurance company. Except with ERISA governed policies, an internal appeal is not necessary to seek relief in Court. In many cases it will be futile and an unnecessary delay to file an internal appeal if an insurer has already made its position regarding a denial clear. Further, it is another option in certain exigent circumstances to skip an internal appeal and seek an independent medical review. That said, such a step can have its own potentially negative consequences.

If its constructive to seek an internal appeal, understand that each insurance company has a different internal appeal procedure. You need to determine the appeals process and follow it. If you write an appeal letter, include your name and contact information such as your address and phone number. Also include information about your policy including the policy number, the group number, and the claim number. You should also include as much written evidence as you have like doctors’ letters and medical records. It is crucial to submit as much evidence as possible from physicians and other health care providers. This information should specify why the treatment is medically necessary and why the denial is improper.

It is important to keep in mind that many companies have time limits for their internal appeal process. When you receive a denial of a coverage claim, immediately investigate the time requirements for the internal appeal process. This way you can determine when you have to file an appeal should you choose to do so.

What can I do if I lose a health insurance appeal?

Generally, you have multiple options including seeking a second level appeal if your insurer provides for one. You can also file a complaint with a state regulator or file a lawsuit. If you lose a health insurance appeal, your first step should be to contact an experienced health insurance attorney. A health insurance attorney like Scott Glovsky can help you understand the options appropriate for your particular case.

What do I do to get quick approval from my insurance company for cancer treatment/emergency treatment/urgent surgery?

If you have a true emergency and need immediate treatment, then your health should be your first concern. One option would be to get the treatment, if available, and worry about your insurance at a different time. Sometimes though, providers won’t offer medications, infusions, surgeries or other treatments without knowing there is insurance available to pay. In such cases, you and your provider should submit an urgent request for coverage. You should request the insurer to handle it on an expedited basis. With such a request, it is important to include as much information as possible. Here, explain your diagnosis and the service for which you are asking for coverage. Also describe the consequences you will suffer if you do not get the service immediately. It is also important to provide as many relevant medical records as possible.

What do I do if my insurance company will not pay for expensive medication?

Insurers will often find reasons to deny expensive medications. The less money an insurer pays out, the greater its profits are. If a health insurer in California denies you benefits for expensive medications, you have several options to fight that denial. These options include submitting an appeal to the insurer, filing a complaint with a state regulator, and filing a lawsuit. Which of these options is appropriate will depend upon the particular facts of your situation. You should contact a href=”https://scottglovsky.com/contact-us/” rel=”noopener noreferrer”>bad faith insurance attorney as soon as you receive a denial to discuss your options.

What is a healthcare attorney?

A healthcare attorney can be one who represents doctors, medical groups, independent physician associations and/or health plans in regulatory disputes.

What is a health insurance attorney or a bad faith attorney?

This is an attorney who represents people to fight insurance companies when they deny coverage for medically necessary treatments. The Law Offices of Scott Glovsky are health insurance or bad faith attorneys.

Am I more likely to get denied if my plan is an HMO vs. a PPO?

An HMO is a health plan through which a member is generally not responsible for certain health care costs. This is true only if the member seeks treatment from providers within the insurer’s network. HMOs provide no benefits for out of network provider costs. A PPO is a health plan through which a member can have their health plan pay certain health care costs. This is true regardless of whether the provider the member sees is in the insurer’s network of providers. However, there is a difference in a PPO if the provider is in-network or out-of-network. The percentage of each bill paid will be higher if the provider is in-network than if the provider is out-of-network.

Both an HMO and a PPO make less profit the more they have to pay out for member benefits. Both, therefore, have an incentive to deny coverage. However, members are required to pay higher portions of the costs of treatments in PPOs than in HMOs. This means that HMOs have a stronger monetary incentive to deny coverage than a PPO.

What can I do if I win an appeal with the DMHC but my insurance company still will not approve a treatment?

It is rare that insurers will not abide by a ruling from the DMHC, California’s regulator for health plans. However, it does sometimes happen. In such circumstances, you can make another complaint to the DMHC. Unfortunately, it is unlikely that if your insurer ignored the DMHC before that it will listen to them now.  You can also file a lawsuit against the insurer.  For this reason, your first action should be to contact an experienced health insurance attorney.

What types of insurance disputes does your firm handle?

The Law Offices of Scott Glovsky represents people in all types of disputes they have with their health insurance companies. This includes fighting insurance companies that deny coverage improperly and that harm their insureds with deceptive practices. It also includes fighting insurance companies that injure their insureds with unreasonable conduct. If you have any questions about whether our offices can help with your health insurance related dispute, please contact us.

What damages can be recovered in a bad faith case?

Someone who brings a successful bad faith case can recover money for all injuries suffered from the insurance company’s denial. This can include money for pain and suffering, emotional distress, physical injury, and lost wages. It can also include lost earning capacity, attorney fees, other economic injury, and even potentially punitive damages.

What are an insurance company’s duties to its insureds in California?

To understand the duties that insurance companies owe their insureds, you should look at this article.