Did You Pay Up Front to Get Stabbed in the Back?
Like most people, you have likely been paying your health insurance premiums for a very long time. It can be extremely frustrating to find out that your health insurance company is now refusing to take care of you and your medical needs. If you have been denied medical treatment or service, now is the time to take action. You need an attorney who is not afraid to jump into the fray, fighting big insurance companies like Anthem Blue Cross, Blue Shield of California, Health Net, Kaiser Permanente, Aetna, and United Healthcare.
Scott Glovsky is that attorney—Scott goes after insurance company big shots who value their lifestyle more than your life and your health. Scott is happiest when he is fighting injustice, particularly injustice perpetrated by big corporations that think they are untouchable. Scott will fight for justice for you because he truly cares about you, your story, your health, and your future. Scott’s hard-fought case victories have impacted millions of policyholders by forcing insurance companies to change their behavior—including their process of reviewing requests for medically necessary treatments.
Scott Glovsky $9.29 Million Kaiser Permanente Insurance Denial Case Result
Why are Health Claims Denied by Kaiser Permanente?
Health care expenses have been cited as one of the leading causes of bankruptcy in the United States. In many cases, this can be directly correlated to a health care insurance claim being denied. Kaiser Permanente and other health management organizations often deny health insurance claims for the following reasons:
- A service or procedure is not covered under the claimant’s policy
- A procedure is considered experimental, cosmetic, or is intended for investigation
- The procedure required a pre-authorization that was not provided
- The services and/or healthcare provider selected is out-of-network
- Administrative or typographical errors
- There is insufficient evidence of a medical necessity
Health insurance providers have a legal obligation to handle all health insurance claims in good faith. According to Gruenberg v. Aetna Insurance Co. (1973), if a health insurer such as Kaiser Permanente “fails to deal fairly and in good faith with its insured by refusing, without proper cause, to compensate its insured for a loss covered by the policy, such conduct may give rise to a cause of action in tort for breach of an implied covenant of good faith and fair dealing.”
When a person’s health insurance claim is denied, it could mean that they do not receive the medical care that they need. Alternatively, an insurance company may deny a claim after a service is already rendered, leaving the policyholder to struggle with massive bills. No matter why your coverage for a treatment, service, drug, or procedure is denied, Kaiser Permanente is required to provide a written explanation for the denial, including how the denial can be appealed.
An experienced Kaiser Permanente health insurance denial lawyer like Scott Glovsky can help you appeal your denial of coverage, whether it involves an outright denial of a service, treatment, or drug, or a refusal to reimburse treatment you have already received. When you have a highly skilled health insurance denial attorney on your side, it is much easier to ensure enforcement of your insurance policy.
What Should You Do if Your Kaiser Permanente Health Insurance Claim is Denied?
When Kaiser Permanente denies a health insurance claim, the claimant may appeal this decision. For information on fighting your denial, download our eBook. According to a report released by the United States Government Accountability Office, a majority of claims that are appealed are reversed in the consumer’s favor.
Appealing a health insurance denial requires understanding the complexities of medical insurance laws and the California Insurance Code, as well as how to navigate through Kaiser Permanente’s confusing appeals process. An experienced Los Angeles Kaiser Permanente health insurance denial lawyer can help guide individuals and their families through this complicated process and work to ensure their appeal is given the attention it deserves.
According to Kaiser’s website, if you are denied coverage for a medical service or payment of a claim, you have the right to appeal that decision through a first-level appeal process, with an optional second-level review available (unless your contract states otherwise). If an appeal is not resolved to your satisfaction, you may be eligible for an independent review by a plan-specified entity or a state-certified independent review organization. Kaiser Permanente will pay for this review; however, you must abide by the decision rendered by the independent review organization. For this reason, it is important to get a Kaiser Permanente health insurance denial lawyer, like Scott Glovsky and his team, early.
Medicare and federal plan members must follow the independent review process administered by the individual programs. To begin your initial appeal, you or your attorney will complete the Member Appeal Request form and return it to the Member Appeals department. If a delay in your appeal could seriously impact your health, either you or your physician could request an expedited review process, which provides a determination on the appeal within 72 hours. If your denial document states the payment is the provider’s responsibility, rather than yours, then your provider must submit the reconsideration request—you may not appeal on behalf of your provider.
If you believe your health insurance claim was unfairly handled by Kaiser Permanente, contact a Los Angeles Kaiser Permanente health insurance denial lawyer today. A seasoned attorney can help you and your family work to hold this large insurance provider to their word and potentially secure the benefits you deserve. Call today to schedule a consultation.
Kaiser Permanente Medi-Cal Plans
In California, patients can get Kaiser Permanent through Medi-Cal in most counties. Medi-Cal offers free or low-cost healthcare coverage to residents who meet eligibility requirements. If you are a member of Kaiser Permanente and your financial situation changes, you may be able to keep your same doctor and continue with Kaiser Permanente if you otherwise qualify for Medi-Cal. Members of Kaiser Medi-Cal can receive such benefits as regular doctor’s visits, mental health and addiction care, prescription medications, and child check-ups.
What Steps Should You Take if Kaiser Denies Your Medi-Cal Claim?
If your care or your child’s care is delayed, denied, reduced, or stopped by Kaiser Medi-Cal, you have the right to have that decision reviewed and reversed. You can file an appeal, ask for a State Fair Hearing, or submit a grievance without fearing any reprisal from the company. That means that whether your appeal or grievance is successful or not, you will not lose your Kaiser Medi-Cal coverage because you took action. If you choose a State Fair Hearing, you will have the opportunity to speak before a judge to review a decision made by Kaiser.
A grievance is for anything you are unsatisfied with, or do not agree with that is not covered by an appeal or State Fair Hearing. You can submit a grievance to your child’s managed care plan for complaints related to covered services, including access to care and the quality of care. If your services are denied, reduced, or stopped, you will receive a written Notice of Adverse Benefit Determination. You must receive this notice at least ten days before the treatment or service is set to be reduced, denied, or stopped.
If you disagree with the decision, you must file an appeal quickly before the services are stopped or reduced. If you need help with your appeal, a State Fair Hearing, or submitting a grievance, you can call the Medi-Cal Member Help Line at 1-800-541-5555.
How Can the Law Offices of Scott Glovsky Help with a Kaiser Permanent Medi-Cal Claim Denial?
It can be demoralizing to receive a denial of service from Kaiser Medi-Cal. It can feel as though justice has been denied, and you may feel as though you are all alone. It is important that you do not give up when faced with a denial of service. You do not need a legion of lawyers to fight back, you just need one person who cares enough about you to fight for your health and your future. Scott’s hard-fought case victories have impacted millions of insurance policyholders by forcing big insurance companies to change their behavior. Scott Glovsky and his legal team are here to help.
About Kaiser Permanente
Kaiser Permanente Health Plan opened to the public in 1945, founded by physician Sidney R. Garfield, and industrialist, Henry J. Kaiser. Unions viewed Kaiser’s prepaid care plan as labor-friendly and affordable. The Kaiser Permanente nurses signed what might have been the first nurse’s labor agreement in the United States with hospitals in Oakland and Richmond, California. The Permanente Medical Group formed in 1948, with seven physicians—a key step in the evolution of the physician-led model.
Kaiser established health plans in regions in Southern California and Hawaii, continuing to expand its diverse pool of highly skilled caregivers, and in 1953, the name Kaiser Permanente was officially adopted. Kaiser continued to develop and grow, and in 1999, a Kaiser Permanente study conducted with the CDC was the first—and one of the largest—studies to identify the link between adverse childhood experiences and health over a lifetime. The study found that children who experienced significant levels of abuse, neglect, and family dysfunction were more likely to develop chronic health conditions later in life.
By 2020, with a pandemic and stay-at-home orders in place, Kaiser’s telehealth visits reached all-time highs. Within weeks, virtual care visits skyrocketed, from 15 percent to 80 percent, with more than 30,000 per day. Kaiser’s mail-order pharmacy dispensary also increased to its highest percentage and volume in history—3.6 million prescriptions in April 2020. Kaiser’s solid technological infrastructure allowed the company to rise to the occasion, ensuring patient safety and patient access during these difficult times.
Kaiser Permanente remains one of the nation’s largest not-for-profit health plans, with 12.4 million members. Physicians are responsible for medical decisions at Kaiser, and the medical groups that provide care for members are continuously being developed and refined with a goal of providing care in the most effective, efficient manner possible. Kaiser has had its share of challenges. In August 2021, the Department of Justice joined together with whistleblowers in a suit alleging Kaiser’s Medicare Advantage plans overcharged the government by making patients appear sicker than they were to receive “risk adjustment” dollars. In August 2022 Kaiser mental healthcare workers went on strike requesting improved working conditions and additional staff to better serve patients.
The Northern California Kaiser strike lasted for ten weeks. And in October 2023, Kaiser agreed to pay a $200 million settlement to the state of California because patients waited 19 days for a follow up mental health appointment instead of the legally allowed 10 day maximum. In April 2024, Kaiser Permanente notified 13.4 million members that their personal information was taken in a data breach after the insurer shared it with advertisers Google, Microsoft, and X (formerly Twitter).
With the ballooning cost of medical care, health insurance is an absolute necessity for individuals and families. Unfortunately, large insurance providers deny health insurance claims all too often, which can threaten a person’s health, livelihood, or impact their family. It can be incredibly frustrating and scary to have a health insurance claim denied.
Furthermore, the process of appealing a denial or filing a lawsuit against an insurance provider can be complex. If you have had a health insurance claim denied by Kaiser Permanente, a Los Angeles Kaiser Permanente health insurance denial lawyer can be an invaluable resource in helping you appeal a decision or file a lawsuit to recover for your damages and losses.
Read Our News Updates on Kaiser Permanente
Kaiser Permanente News
In 2018, Kaiser Permanente was fined $100,000 for its failure to provide appeal information for denied insurance claims to insured individuals. Although Kaiser agreed to correct its actions, a complaint filed by an enrollee sparked a review of the practices of Kaiser Permanente, and multiple violations were found. When examiners reviewed Kaiser’s files between 2016 and 2017, they found that 175 out of 180 letters sent to insured individuals failed to inform the individuals they had only five days to submit additional information for their appeals. Further, the vast majority of complaints received from insured individuals were about authorization disputes and denials.
More recently, months after Kaiser Permanente reached an agreement with state regulators to improve mental health services, union allegations surfaced alleging patients could be improperly losing mental health care. It was alleged that Kaiser was inappropriately handing off decisions regarding whether mental health therapy was medically necessary. More specifically, a contracted network of therapists, Rula Health, was alleged to have been using illegal criteria to make decisions during reviews.
Under California law, decisions regarding mental health care must be based on professional criteria. In this case, the union said there was no evidence that mental health care decisions were properly being based on professional criteria. Instead, Rula Health relied on Kaiser patients’ answers to questions regarding their own symptoms when reviewing treatments. Practically, this meant that many Kaiser Permanente patients were having their access to care unfairly terminated, even when they had a psychological disorder that required extended treatment. The union also alleged that Kaiser was placing barriers to mental healthcare for those they insured – barriers that did not exist for other health conditions.
The California Department of Managed Health Care was asked to order Kaiser to halt its current mental health review process and notify Kaiser patients who had their mental health treatment illegally terminated. Kaiser claimed there was no limit set on the number of therapy sessions allowed and that while patient self-assessment tools could be used as one method of gathering information, they were never the only factor involved in limiting mental health services.
In the fall of 2023, Kaiser was required to pay a $50 million penalty and invest $150 million over the next five years to improve mental healthcare. A California state agency said there were definite problems associated with Kaiser’s failures to provide timely appointments, its inadequate handling of patient grievances, and insufficient oversight of medical groups. Kaiser claimed the mental healthcare surge during the pandemic was responsible for all these issues.
- Kaiser Settles Our Autism Class Action for Denying Applied Behavioral Analysis and Speech Therapy – Agrees to Reimburse Families up to $9.29 Million
- Kaiser Permanente’s Mental Health Workers Strike
- Class Action Lawsuit against Kaiser for denying ASD treatment
- Kaiser Denies Life-Saving Treatment to our Client Jalal Afshar
- USC Hospital Sues Kaiser over Nonpayment of Bill – Scott Glovsky quoted in the LA Times
Kaiser Permanente Health Insurance Denial Lawyer Scott Glovsky: Results
The California Superior Court for the County of Alameda granted final approval of a class action settlement on January 16, 2020, in Charles Dion v. Kaiser Foundation Health Plan, Inc., Case Number RG1718903. The Law Offices of Scott Glovsky represented Charles Dion as the class representative. The lawsuit against Kaiser alleged that the company denied coverage and access to residential treatment for severe mental illness, disregarding proof of medical necessity. Only short-term acute treatment for mental illness was being approved.
Under Kaiser Permanente plans, members have no access to outside mental health providers who do not contract with Kaiser unless specifically referred by Kaiser to an outside provider. This means that a Kaiser member who was unable to access a mental health appointment in a timely manner would be unable to secure mental health treatment.
The class action settlement required Kaiser to provide 105,201 California members of Kaiser Permanent who live with severe mental illness, access to medically necessary residential treatment. Under the terms of the court-approved settlement, Kaiser was forced to agree to make systemic reforms regarding access to mental health treatments. New residential treatment guidelines now include coverage for non-crisis residential treatment for members.
Prior to the above settlement reached by the Law Offices of Scott Glovsky with Kaiser Permanente, Attorney Scott Glovsky had another claim against Kaiser for members in Southern California regarding coverage for autism treatments. The court found that Kaiser’s practice of categorically denying coverage for certain services for autism-related disorders, which were included in the terms of its healthcare plan, was sufficient to support a state class action UCL Claim. More details about the successful results of this class action are outlined below.
The California Mental Health Parity Act mandates that every health care service plan must provide coverage for the diagnosis and treatment of mental illnesses, including autism, under the same terms and conditions as applied to other medical conditions. It was alleged during the lawsuit that Kaiser breached its health plan contract, violating the Act by denying coverage for behavioral therapy and speech therapy to members with autism spectrum disorders.
Autism spectrum disorders are complex neurological disorders of development with an onset in early childhood. These disorders affect the brain’s ability to function, resulting in mild to severe difficulties, including limited social skills, unusual and repetitive behaviors, communication problems, and language delays.
Among other exclusions, Kaiser denied autistic members “custodial care,” which involves assistance with daily living activities. These activities included eating, getting dressed, bathing, walking, taking medications, and getting in and out of bed. These tasks can be performed safely and effectively by caregivers without a medical license.
How Kaiser Permanente Health Insurance Denial Lawyer Scott Glovsky Help You After A Coverage Denial
Like most people, you probably expect your insurance to cover you when you become ill or need a treatment or service. It can be extremely discouraging to receive a denial for a treatment or service your doctor has ordered—and that you need. Attorney Scott Glovsky has been taking on big insurance companies for two decades, helping people just like you in the process. Scott Glovsky got Kaiser Permanente to stop systematically denying Applied Behavioral Analysis and speech therapy to children with autism spectrum disorders.
This decision impacted 45,000 kids with Kaiser insurance, providing a $9,290,000 settlement for class members and autism research. In this case, Scott was a finalist for the 2014 Consumer Attorney of the Year Award from the Consumer Attorneys of California and received the California Attorney Lawyer of the Year (CLAY) award. Scott also got Kaiser to provide more than 100,000 California members living with severe mental illness access to medically necessary residential treatment in a court-approved class action settlement.
As you can see from the above, Scott Glovsky is the Kaiser Permanente health insurance denial lawyer you need in your corner when it is time to fight a big insurance company. Scott can help you file an appeal with the internal processes of Kaiser Permanente, help create a case before the state’s review board, or take your case to court to enforce a policy. If Kaiser Permanente denied your health insurance claim, you need Scott Glovsky in your corner. Contact the Law Offices of Scott Glovsky today to find out how we can help you during this difficult time. We want to make sure you receive the treatment you need while ensuring Kaiser Permanente provides the coverage you were promised.