Every day in Los Angeles and around California, thousands of people rely on their health insurance to issue payments for medical procedures. These procedures can vary from routine check-ups and lab work to emergency surgeries and hospital visits. People who have health insurance expect their policies to cover these costs.
Unfortunately, denials of coverage or service for sick and injured policyholders are common. The insurance companies that administer these policies make their profits by collecting premiums but finding ways to avoid paying for claims. This can include arguing that the care was not medically necessary for the health of the insured, stating the provider is out of network, or claiming the treatment is experimental or a clinical trial.
No matter the stated reason for denying a claim, subscribers generally have the right to appeal. This appeal can be filed with both the insurance company and the State of California. A credible attorney can assist people with this process. A Los Angeles health insurance denial appeals lawyer can work to gather the full details of a person’s medical situation and to leverage these facts into a successful appeal.
How A Los Angeles Insurance Company Can Legally Deny a Claim
Insurance policies are binding contracts. This means that the insurance companies are required to honor their policies when the time comes to pay a claim. However, these companies utilize many strategies to avoid payments that may be valid under California law.
One method is to state that the acquired treatment took place out of network. All insurers have a network of hospitals and doctors with which they have an agreement. This agreement states the insurance company will provide payments for all approved treatment. When someone takes on an insurance policy, they implicitly agree to use providers in the network.
However, there are situations where this is unreasonable. For example, if someone is injured while traveling or are in such a dire situation that they cannot choose their provider, they may be forced to seek out-of-network treatment. In these situations, people may argue on appeal that they had no other choice but to seek out-of-network treatment.
Another main source of conflict is whether the treatment is medically necessary. Insurers only provide coverage for treatment that is likely to result in an improvement in the customer’s health. Therefore, all cosmetic procedures are not included. The same can be said for many experimental treatments. These are not recognized in medical literature and the results are not certain. As such, insurers may be hesitant to provide payments.
How can a Person Appeal a Health Insurance Denial?
No matter the stated reasons for the denial, the appeals process remains the same. All insurers are required under California law to state in writing the reason for denying coverage. They must also provide an internal appeals process and give a minimum of 30 days for policyholders to file appeals.
While California’s laws are somewhat pro-consumer in this regard, these appeals are rarely successful. This is because the appeal is generally handled by the same people who issued the initial denial. To obtain relief, it may be necessary to file an appeal with the State.
California operates their own appeals board that investigates and rules upon issues of medical insurance denials. The Department of Managed Healthcare consists of doctors whose sole purpose is to evaluate medical insurance denials. These boards are impartial and can order an insurance company to approve treatment. Contact a health insurance denial appeals lawyer in Los Angeles to learn more.
A Los Angeles Health Insurance Denial Appeals Attorney Can Help
A denial of coverage for medical treatment despite the ownership of health insurance can place a great burden. People expect that when they need their insurance companies to provide payment in times of sickness or injury they will.
Fortunately, all people who face denials have the right of appeal. This can include filing an internal appeal with the insurance company as well as taking the case to the State of California. In either event, a Los Angeles health insurance denial appeals lawyer could help. These attorneys can fight to force insurance companies to honor their policies and provide payments under their contracts. Contact an attorney today to schedule a consultation.
