If you have been denied compensation when an insurance company has acted in bad faith, you may want to obtain a dedicated lawyer as soon as possible. An accomplished insurance bad faith lawyer could review your case and see if it has means for an appeal. Call today to schedule a consultation with a legal professional who is experienced in the appeal process for insurance bad faith in Los Angeles.
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Employee Retirement Income Security Act Plans
The first question to consider in the appeals process for insurance bad faith in Los Angeles is whether there is a reason to file an appeal. When someone has an Employee Retirement Income Security Act (ERISA) plan, the patient must exhaust their administrative remedies, which may mean pursuing the appeal process for insurance bad faith in Los Angeles. In ERISA plans, it is crucial to include all necessary medical information with the appeals. Under ERISA, there is no opportunity later in a lawsuit to introduce new evidence, as all evidence must be in the administrative record. The documents included in the appeals process are considered part of the administrative record.
It is essential in an ERISA plan to include the letters of all treating physicians explaining why the treatment is medically necessary and covered under the plan in the initial appeal. Further, it is helpful for the treating physicians to describe in their letter the adverse health outcomes that could result in the denial and delay of medical treatment.
Likelihood of Winning an Appeal
It could be helpful for an insured individual to get a second opinion from another doctor and have that doctor provide a similar letter for the appeal. For policyholders that are not in an ERISA plan, the appeals process is often pointless.
Health insurance companies have national guidelines describing the circumstances under which they cover various medical services. Medical reviewers often uphold the initial denials of treatment based on the same policies and procedures. It may be more likely to get prompt medical care when a bad faith insurance lawyer quickly files a lawsuit challenging the denial. The appeals process for insurance bad faith in Los Angeles is complex, however, a seasoned lawyer could review the case and see if there were, in fact, liability issues.
Increase Your Odds of a Successful Appeal
There are several steps you can take to increase the odds of a successful appeal including those below:
- Do your research and include details. Understand your insurer’s appeal process and act quickly. Include all important information in your appeal like the date of service, your details (claim number, insurance ID, date of birth), etc.
- Write down the reason for your denial. Keep in mind that it might be something that is easily corrected like a coding error or incomplete information.
- Be specific, detailed and concise. Clarify why the medication or treatment is medically necessary. Include supporting data like a doctor’s letter, laboratory numbers, medical records, and more. Describe how this treatment will alter your health and your life.
- Leverage independent 3rd party professional associations or societies. Perhaps your request is in fact the standard of care to treat your health concern. It is not unusual for certain insurers to deny what others say is medically necessary merely because their internal policies are not current with the latest medical information.
- Keep good records. Have notes about every encounter with your health insurer, physicians, facilities, etc. Notate the names of people you speak with, when you spoke to them, what was talked about, what they said would happen, and so on. Ask them about follow up and if you need to do something or if they will reach out to you. Keep copies of all letters, documents, proof of your submissions, forms, and more. Create a timeline of what happened and when.
Who is Involved in an Appeals Process for Insurance Bad Faith in Los Angeles?
In California, the health insurance companies such as Anthem Blue Cross, Blue Shield of California, Health Net, United Healthcare, Kaiser, and Aetna have similar appeals processes for denials of health insurance treatment. Generally, the health insurance companies have an administrative person or an automated system that sends out a letter acknowledging an appeal of a denied medical claim.
The health insurance companies have medical review nurses, called pre-certification nurses or utilization review nurses, who review the documents submitted with the requests for medical treatment and make recommendations about whether the health insurance company should authorize or deny the medical treatment. In California, only licensed and appropriate medical professionals can deny treatment, which means nurses cannot deny medical treatment.
The medical review nurses review the medical records and may authorize the medical treatment if the insurance company gives them that power. If the medical records reflect that the treatment should be covered according to the insurance company’s guidelines, nurses may be able to authorize treatment. If the nurses do not believe they can authorize treatment or if the medical information provided does not meet all the guidelines for the specific insurance company, the utilization review nurses add a brief description into the insurance company’s database.
Review Process of an Appeals Request
Many nurses work from their homes on laptops around the country. Once the nurse makes their recommendation, it is reviewed by a medical doctor somewhere in the United States. The medical doctor, often called the medical director, reviews the request and makes a determination to authorize or deny the medical treatment. Because insurance companies have a duty to engage in a thorough, fair, and full investigation, they cannot deny treatment without performing a full investigation. However, this almost never happens. The insurance companies review appeals using a form with boxes to check. If they cannot check all the boxes in their checklists, they deny treatment. If the medical reviewers, utilization review nurses, or medical directors are missing any information the insurance company deems necessary, they deny treatment even if the medical treatment is obviously necessary.
To learn more about the appeal process for insurance bad faith in Los Angeles, reach out to an accomplished bad faith lawyer today.
