Navigating any insurance policy can be difficult. Policies are frequently confusing. Making matters worse, insurance companies are generally motivated to deny as many claims as possible to maximize their profits. When an insurance company breaks its promise to a policyholder, it acts in “bad faith.” The task of holding an insurer accountable may feel like a David vs. Goliath situation. Luckily, there are lawyers who specialize in a wide variety of insurance types and situations. In the field of health insurance, there are many attorneys who specialize in the various facets and types of different health insurance plans. These attorneys make it their business to go up against the giant corporations that administer health policies. A phone consultation and doing some online research can make the process of hiring a health insurance attorney feel much more comfortable. This article discusses why and when to hire a health insurance attorney.
How do I know if I need to hire an insurance lawyer?
- You are getting the runaround from your insurance company when you need care. When an insurance company denies a request for care, you have a couple of options. You can appeal the insurer’s decision and it will review the decision to see whether it is appropriate. If an appeal request results in the same determination, ask a health insurance lawyer if the insurer is acting in bad faith.
- Your insurance company terminated your policy without reason. An all too common scenario is a person receives medical care, and then the insurer terminates the plan without the member’s knowledge. This leaves the person in a lurch and responsible for those medical bills. If an insurance company unjustly terminates a plan without proper notification, it may be violating the law. A health insurance attorney can review the situation to determine whether the plan cancellation was warranted.
- You received a denial, delay, or reimbursement underpay. As noted above, insurers will often deny requests for care. These denials can be issued for a multitude of reasons which are outlined below. Additionally, insurance companies will often do all they can to delay determining or reimburse only some of the costs related to treatment. A health insurance lawyer can help determine which actions are legal and which constitute health insurance bad faith.
What are the common reasons health insurers give for denying, delaying, or underpaying a claim?
- Experimental or investigational. Insurers will often use this reason as an excuse to deny specialized or emerging forms of care. Doctors and specialists are the ones most knowledgeable in these areas. However, insurers often rely on outdated facts and data to insist that their determinations are correct. A health insurance attorney can help determine whether there are sufficient facts to back up an argument.
- Not medically necessary. This is one of the most common reasons that health insurance companies provide for denying medication, care, or treatment. It often pits the patient’s own doctors and specialists against the insurer, leaving the person stuck in between. A strongly worded letter affirming medical necessity and relevant medical records can be helpful in fighting a lack of medical necessity determination.
- Out of network or not in network doctor or facility. Most insurance plans consider medical providers either “in network” or “out of network.” Plans bill their members according to these distinctions, and typically bill more for out of network providers. It is important to determine whether a provider is in network or out of network before engaging with them. You should call your insurance provider directly and ask whether a particular provider is in network. You can also look on the insurer’s website to see if the provider is listed as in network. In addition, it is always a good idea to ask the provider directly. Ask the provider if it is in network with your insurance company and particular plan. When there is a disagreement about whether a provider is out of network, a health insurance attorney can help.
Other reasons health insurers give for denying, delaying, or underpaying a claim
- Non-essential or elective procedure or treatment. This denial reason is similar to “not medically necessary,” but differs slightly. Non-essential or elective procedures are those that might be considered superficial, strictly cosmetic, or don’t satisfy an urgent medical need. A doctor’s note and supporting medical records can help in fighting back against this type of decision.
- Incomplete or inaccurate insurance information. Check with your insurance provider to make sure you fully understand the details of your policy. If they tell you something that you know is at odds with your understanding of the policy, you may want to have an attorney review the policy.
- Request is missing diagnosis or procedure codes, or the codes are incorrect. This situation often leads to a vicious back and forth cycle between the insurance company and the companies that process billing. When these delays go on for too long, it can damage a patient waiting for meaningful or life-changing medical care. An insurance attorney can help determine whether there is a valid issue with medical coding.
- Absence of prior authorization or pre-certification. Insurance policies may have provisions that require prior authorization or pre-certification for certain medications, treatments, or procedures. Such instances should be laid out in the insurance policy. A health insurance lawyer can help review a policy to determine when prior authorizations are legally required.
Even more reasons health insurance companies give for denying, delaying, or underpaying a claim
- You haven’t hit your insurance policy deductible payment. A deductible is the amount you must pay for covered health care services before the insurance company starts to pay claims. Understanding your deductible, and what amount you have paid towards it already is important in navigating any health insurance policy. The insurance company can always answer questions regarding this topic over the phone.
- You need other procedures or tests prior to getting this treatment. If your claim was denied or delayed for this reason, you have options. Talk to the doctor who is recommending the treatment and ask whether he or she agrees with the assessment. If the doctor strongly disagrees with the insurer, you may want to have an attorney review your situation.
- Your insurance plan doesn’t cover this type of care. In this case, a thorough understanding of your insurance plan is critical. Have the insurer explain exactly where in your policy it states that it does not cover that type of care. If you disagree with its interpretation, you may want to have an attorney review your policy.
- The injury happened a long time ago and the filing date has passed. Time limitations on certain claims do exist. Sometimes, however, circumstances can arise in which a claim may still be pursued. If an insurer denies for this reason but you disagree, a health insurance lawyer may be able to help.
- You didn’t pay your co-pay amount. A co-pay is simply the percentage of the claim amount that must be paid by the policyholder. This is typically a set amount and can be found in the insurance policy itself.
What will a health insurance lawyer I reach out to ask me?
- Who is your insurance company? Check your insurance policy or insurance card for this information. Carrying a copy of your insurance card on you always is a good idea.
- Did you or your family purchase this insurance or is it through your work? It is important to know your type of health insurance plan. An individual plan is one that you or your family purchased on your own. A group plan is one that you receive through an employer. If you have a group plan, is your employer providing the insurance a private company or a government entity?
- If your insurance is through your work, is the plan “self-insured?” A self-insured or self-funded plan is one where the employer assumes the financial risk for providing health care benefits to employees. To find out whether a plan is self-insured, ask your employer providing the benefits.
- Is your plan through Medi-Cal or Medicaid? Medi-Cal is California’s Medicaid program. Medicaid is a federal and state program that helps with medical costs. It is important to know whether you receive Medi-Cal and/or Medicaid benefits before pursuing an insurance claim.
- Do you have a copy of your insurance policy Statement of Benefits? If you do not, you can request this from your insurance company.
Other questions you may need to investigate for the health insurance attorney
- Is your plan an ERISA plan or a non-ERISA plan? ERISA stands for The Employee Retirement Income Security Act of 1974. ERISA applies to private-sector companies. In general, ERISA does not cover health plans established or maintained by governmental entities or religious organizations for their employees. Also, ERISA does not cover plans that are maintained solely to comply with applicable workers compensation, unemployment, or disability laws.
- Do you have records of your interactions with doctors, facilities, and the insurance company? The more documentation you have of correspondence between your treating doctors, facilities, hospitals, and insurance company the better. Legal disputes commonly come down to how well events are documented and the actual correspondence between your doctors and your insurer. Do your best to diligently keep records of all these communications including letters, emails and phone calls.
- Have you enlisted your doctor to help reverse this denial? Your doctor’s involvement can often help to resolve insurance disputes involving denials quickly and efficiently. If you experience a denial or delay, ask your recommending doctor to help you. As if he or she will communicate with the insurance company regarding the necessity of your treatment.
How much will it cost to hire a health insurance attorney?
Some lawyers charge by the hour and others charge by the case. There are many attorneys, however, who take insurance cases on a contingency basis. Contingency lawyers only bill you if they can secure a recovery on your behalf. The good thing about a contingency lawyer is that you don’t have to pay. Also, this type of lawyer believes you have a winnable case. Ask the attorney a lot of questions like those listed here. And be careful to watch out for attorneys and law firms who try to settle cases quickly for less money.
About the Law Offices of Scott Glovsky
The Law Offices of Scott Glovsky specializes in health insurance law. We have represented injured consumers and victims of wrongful business practices for more than the past two decades. Scott Glovsky is recognized as one California’s most experienced, compassionate, and trusted insurance law attorneys.
For a free case evaluation, contact us.