Appeal Process for Insurance Bad Faith in Los Angeles

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.

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.

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.