Los Angeles Health Insurance Denial Appeals Lawyer

Appealing a Health Insurance Denial

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 sometimes 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 often leverage these facts into appealing a health insurance denial successfully.

How A Los Angeles Insurance Company Can Legally Deny a Claim

Why do insurance companies deny claims for medical treatments, services, or prescription drugs? Insurance policies are binding contracts. This means that insurance companies are required to honor their policies when it comes time 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 treatments. When someone takes on an insurance policy, they implicitly agree to use providers in the network. In fact, most insurance plans have different deductibles for in network and out of network providers and facilities.

However, there are situations where this is unreasonable. For example, if someone is injured while traveling or is 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 improve a patient’s health. Therefore, most cosmetic procedures are not included. (Some cosmetic procedures are covered when they are tied to medically necessary treatments such as breast reconstruction after a breast cancer mastectomy.) The same can be said for many experimental treatments. In this case, these are not recognized in medical literature, and the results are not certain. And sometimes this is due to out-of-date medical. As such, insurers may be hesitant to provide payments.

While there are valid reasons that a medical claim for treatment, services, or prescription drugs can be denied, in truth, the most common reason for insurance claim denials comes down to one thing—money. Insurance companies are in the business of making money, and their business model is set up to ensure they continue to be profitable. While the reasons given for a medical insurance claim denial are often cloaked behind words like “not medically necessary,” “experimental,” or “investigational,” what this can mean is “the treatment is too expensive.” It is rare that a treatment that does not cost much is denied, even if it actually is experimental or investigational. As far as saying a specific treatment is not medically necessary, that is a determination that should be made by medical professionals rather than insurance companies.

Who is Involved in a Denial Process for Insurance Bad Faith in Los Angeles?

In California, health insurance companies such as Anthem Blue Cross, , Health Net, United Healthcare, Kaiser, Aetna, and Medi-Cal Managed Care plans have similar processes for denials of health insurance treatment. Generally, health insurance companies have an administrative person or an automated system that sends out a letter acknowledging n denied medical claim.

Health insurance companies often 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 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 to the insurance company’s database. And sometimes, a nurse can approve treatment but must bring a physician in to review the claim if the nurse plans to deny it based on medical necessity.

What Is the Process for Appealing a Health Insurance Denial?

No matter the stated reasons for the denial, the appeals process remains the same. Under California law, all insurers are required to state in writing the reason for denying coverage. They must also provide an internal appeals process and give policyholders a minimum of 30 days to file appeals.

While California’s laws are somewhat pro-patient 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 its own appeals board that investigates and rules upon medical insurance denial issues. 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. There is a specific process for appealing a health insurance denial for a treatment, procedure, or prescription drug, which includes:

1. Determine what type of insurance you have and know your rights. The procedure for appealing an insurance claim denial depends to some extent on whether you get your insurance through your employer, a managed health care plan company, a self-insured association, or the government. Check your enrollment form to determine what type of policy or plan you are enrolled in.
2. Read through your plan to make sure you understand what your benefits under the plan are. If you do not have a copy of your benefits, often found under Evidence of Coverage, call your insurance company and ask where you can find your benefits. California has laws relating to the Patient Protection and Affordable Care Act that define the minimum benefits. Under the Affordable Care Act, coverage must include essential health benefits, including:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health care
• Substance abuse services
• Behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory Services
• Preventative and Wellness Services
• Chronic Disease Management
• Pediatric Services, including oral and vision care

3. You must understand your rights before you begin the appeals process. If the benefits listed under your plan are not explicit, this is likely intentional. A health insurance company can more easily deny coverage for benefits if it is not clear under the plan whether the service, treatment, or drug is covered. Many people covered under health insurance may not fully understand their rights, so they will not appeal the process – which is what the insurance companies probably are counting on. Mental health treatments are the treatments most often denied but may be required under the law. If you are unsure whether a service is covered under your plan, speaking to a knowledgeable California health insurance appeals lawyer can be helpful.
4. Make sure you have all the necessary information and documents regarding your claim or treatment denial. If you have had any communication with your insurance company regarding the denial, make sure you document everything. Put together a file with copies of all the letters sent to you by your insurance company and any notes on phone calls you have had with a representative of the insurance company, including the name, title, and employee ID number of the representative as well as everything that was said during the conversation. Your file should also include copies of your medical records and any referrals from your health care professionals. Make copies of all this information for your appeal, but keep your originals. Your Los Angeles health insurance denial appeals lawyer can ensure you have all the necessary information for appealing a health insurance denial.
5. Begin your internal appeals process by reading through the information about the appeal process of your specific plan. If you cannot find the appeal process, call your insurance company and ask for a copy of the appeal process. A California health insurance appeals lawyer can make this process much easier while giving you a greater chance of success with your appeal. Your plan will give you the specific amount of time you have to file an internal appeal after you have received a denial letter from your insurer. Your lawyer can help you structure your appeal so that you get the results you deserve. Your appeal letter must include your name, contact information, policy number, group number, and claim number. Include as much written evidence to support your internal appeal as possible, including a letter from your healthcare provider or providers detailing the need for the service, treatment, or prescription drug and any medical literature that describes the efficacy of the treatment. It is important that you do not miss the deadline for your internal appeal, or you could lose your right to appeal altogether. An internal appeal is essentially asking your insurance company to reconsider its decision and approve your claim.
6. You can begin an external process if your internal appeal is also denied. This is where your claim is reviewed by a neutral third party and can be helpful in getting your denial reversed. Talk to your Los Angeles Health Insurance Denial Appeals Lawyer before you pursue an external appeal. If you have received a bad faith insurance claim denial, the external appeal may not be a prerequisite to seeking court intervention. It may be more efficient to skip the external appeal and go straight to a lawsuit to get the coverage you need and deserve. If your attorney believes it will be best to pursue an external review before engaging in litigation, your external appeal will move forward, based on the information you provide. If you are a member of a managed health care plan, then you will seek a review from the Department of Managed Health Care (“DMHC”). Whereas, if you are covered by a health insurance company, then you can seek a review from the California Department of Insurance (“CDI”). Both the CDI and the DMHC have similar appeal procedures. After you determine whether your claim is regulated by the DMHC or the CDI, then you should visit the website of the particular agency that governs your claims’ external appeal. You can also call the DMHC at (888) 466-2219. You can also reach CDI at 800-927-HELP (4357). Both the DHMC and CDI have detailed information on how to file a complaint for an external appeal. Generally, the information that you provide to them will mirror the information and documents you provide to your insurance company or health plan provider when you seek an internal appeal. If the external review results in a reversal of the denial of your claim, your insurance company must abide by that decision.
7. If the appeals process is unsuccessful or if you decide to skip the external appeal, you can file a lawsuit against your insurance company. Once you file a lawsuit, there is pressure on your insurer to do the right thing and approve your treatment, service, or prescription drug. An insurer who ignored you before will likely sit up and take notice once you have initiated legal action. Not only could a lawsuit result in complete coverage for the denied treatment, but you could also be entitled to additional monetary awards for your insurer’s bad faith actions in denying your claim. If your lawyer files a bad faith lawsuit on your behalf, it will likely be on a contingency basis, which means you will not pay your attorney unless the case is won. At that time, the attorney will take an agreed-upon percentage of the award.

Why Is Appealing a Health Insurance Denial Important?

You should always appeal a denied healthcare claim. Not only is it important for your health and your future, but insurance companies should not be allowed to deny treatments that they should pay. You have spent years, possibly decades, paying for health insurance. You make your payments faithfully, expecting that when the time comes that you need healthcare treatment, your insurer will have your back. Many people do not think an appeal will be successful, do not know how to file an appeal, or do not have the necessary time to figure out the process. Do not let this happen! Contact an experienced California health insurance appeals lawyer from the Law Offices of Scott Glovsky to help determine how you can get your denied claim approved. 

What Are ERISA Policies?

If you are covered under a plan provided by your private company employer, it is likely your plan is covered under the Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA is a federal law and these plans are not governed by state laws. This means that your remedies are extremely limited. Despite this, it is a good idea to speak to a knowledgeable ERISA attorney who can clearly lay out your options, helping you determine whether appealing a health insurance denial is the right choice.

What Are the Unique Processes Tied to ERISA Appeals?

The ERISA appeals process is a little-known landmark federal legislation that can recover money insurance companies owe medical providers and patients for older claims and denials. If a claim has been underpaid or rejected, federal law trumps insurance policies, but the claim denial appeal is complex and beyond the capabilities of most patients. Even at large hospitals, there are few staff members who have the expertise to pursue federal ERISA appeals. For these reasons, you need an attorney with extensive experience in ERISA appeals.

How Can You Improve Your Odds of Winning an Appeal?

Those who have a highly skilled Los Angeles Health Insurance Denial Appeals Lawyer by their side are much more likely to win an appeal after a claim denial. It is extremely important that you accurately identify why your claim was denied. In some cases, the denial may be for something simple that you can easily correct. Join forces with your doctor to put together compelling evidence that shows the treatment, service, or prescription drug is medically necessary, and is not experimental or investigational.

The information may include relevant information regarding your medical history, medical journal information regarding the efficacy of the proposed treatment, and a letter from your medical providers that will clearly detail why you need this treatment and what could happen to your health if the treatment is denied.

Make sure all your appeal paperwork is submitted before the deadline dates. Each level of appeal has different submission deadlines established by your insurer. Contact your health insurer directly to make sure you are certain of these deadlines. It is also a good idea to send your appeal documentation via certified mail with a tracking receipt so your insurer cannot say it never received your appeal information. 

Why Do You Need an Attorney to Help with Your Claim Denial and Appeal?

When you are counting on insurance coverage for a health issue, a denial can be devastating. Not only can a healthcare claim denial leave you unable to get the healthcare you need and deserve, but it can also cost you money you do not have while shaking your faith in the entire system. While appealing a health insurance denial on your own is an option, having an experienced California health insurance appeals lawyer can make a significant difference in the outcome of your appeal. Plus, if it turns out that your insurer acted in bad faith, your attorney will have all the necessary information to file a lawsuit against your health insurer. Your attorney can:

• Ensure you fully understand your insurance policy and rights while helping you navigate the process with the assistance you need.
• Decode the fine print in your insurance policy; your attorney is trained to decipher complex legal language and confusing terms.
• Ensure your appeal aligns with any state laws and government regulations regarding the California insurance claims and appeals process.
• Build a strong case by gathering all the evidence and presenting a compelling argument as to why your claim should be paid.
• Organize and present your case clearly and concisely, crafting a narrative that highlights its merits.
• Challenge insurer bad faith when your insurance company acts in a deliberately misleading manner while identifying violations of your rights.
• Aggressively negotiate and/or litigate on your behalf, using tactics that will convince the insurer to settle your claim in a positive manner.

When you are facing a denial, choosing the right attorney can have a significant impact on appealing a health insurance denial. Seek an attorney who has a proven track record and a history of success in health insurance claim denials as well as acts of bad faith on the part of an insurance company.

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 company to provide payment in times of sickness or injury it will.

Fortunately, all people who face denials have the right to 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.

About the Law Offices of Scott Glovsky

The Law Offices of Scott Glovsky has represented injured consumers and victims of wrongful business practices for more than the past two decades. The firm focuses on health insurance bad faith, catastrophic personal injury, sexual abuse, and consumer-related litigation. We get justice for our clients and hold the wrongdoers accountable. If you have been denied treatment, we can help.