How to Deal with Underpays or Delays by Your Health Insurer
Whether you have OSCAR Health Plan of California or another healthcare insurer, you may have experienced being denied coverage for a necessary test, procedure, or prescription drug. Such a denial can send your world into a tailspin. What will you do when you cannot afford to pay for the procedure, test, or prescription drug out-of-pocket? You may be wondering what steps you need to take to address this injustice but are too busy trying to keep your head above water financially while experiencing a healthcare issue that you simply do not know which way to turn. Here’s what you need to know: All it takes is one solid advocate in your corner—one person, one law firm that is willing and able to fight for you. One advocate that genuinely cares about your health and your future.
Attorney Scott Glovsky is the lawyer you need at this moment in time. At the Law Offices of Scott Glovsky, we fight for every one of our clients as we work to force their insurance companies to change their behavior and follow through with the commitments they made to you when you signed on. Using every legal measure at our disposal, we will work hard to force your insurance company to do the right thing. Attorney Scott Glovsky can beat up your insurance company—just ask Anthem Blue Cross, Blue Shield of California, Health Net, Kaiser, Aetna, United Healthcare, and OSCAR.
About OSCAR Health Plan of California
OSCAR is one of the newer health insurance companies and was founded in 2012 with a technology and telemedicine focus. A for-profit company, OSCAR Health, Inc. went public and entered the New York Stock Exchange in March 2021. OSCAR is not profitable. The company had a net loss of $609 million in 2022 and as of February 2023, expects to lose $75 million to $175 million in 2023.
At the end of 2022, OSCAR served 1.15 million members comprised mostly of individual and small group plans. OSCAR started offering individual insurance plans in California in 2016 and became available as a health insurance option for those living in both Los Angeles and Orange Counties. At the end of 2022, OSCAR reported it had over 62,450 enrollees in California. In addition to individual and family plans, OSCAR has employer plans as well as Medicare Advantage plans.
Summaries of Cases We Have Filed
- We filed a case against Oscar Health Plan of California for denying a medically necessary MRI for our client. Our client had numbness and weakness in his lower extremities. His doctors requested MRIs to determine the cause of his symptoms. However, Oscar Health Plan denied the crucial requests, delaying his care for months and causing lasting physical injury and emotional distress. Our lawsuit alleges that Oscar’s system for reviewing requests for medical care is designed to deny medically necessary care to its subscribers, placing barriers in the way of members receiving necessary care and designed to save money for Oscar. As a result of Oscar’s wrongful denial, our client suffered physical injury, emotional distress, and other damages. We are suing Oscar for breach of the duty of good faith and fair dealing, breach of contract, and violation of Business & Professions Code Section 17200.
- We filed a case against Oscar Health Plan for denying medically necessary emergency treatment. Our client, nine months pregnant, had a traumatic injury after a head-on collision and was rushed to the hospital. Oscar denied coverage for these emergency services and our client was left with tens of thousands of dollars in medical bills. Our lawsuit alleges that Oscar’s utilization review system systemically fails to conduct full, fair, and thorough investigations before denying coverage. We are suing Oscar for breach of implied covenant of good faith and fair dealing, breach of contract, and violations of Business & Professions Code Section 17200.
- We sued Oscar Health Plan for denying our client’s medically necessary emergency treatment. Our client went to an emergency room with severe abdominal pain and needed emergency surgery to remove his gallbladder. Oscar denied pre-authorization for surgery at this emergency room and caused our client to be transferred to an in-network facility, causing considerable and unnecessary pain. Despite receiving an Oscar Explanation of Benefits form claiming all balances were paid, our client received bills over two years later from two providers because Oscar denied coverage for the treatment. Appeals were unsuccessful, leaving our client burdened with medical bills that Oscar refused to cover. Our lawsuit alleges Oscar’s actions were indicative of bad faith conduct, as they systematically failed to conduct thorough investigations before denying coverage. The complaint alleges that Oscar’s utilization review system only allowed reviewers to assess limited information, failed to conduct fair and thorough investigations, and utilized software that discouraged comprehensive reviews. Furthermore, the lawsuit alleges that Oscar incentivized its reviewers to unreasonably deny coverage and forced members to receive emergency care at in-network facilities. We are suing Oscar for breach of the implied covenant of good faith and fair dealing, breach of contract, and violations of business and professions code section 17200.
News Related to OSCAR Health Plan of California
In August 2021, the Department of Managed Healthcare (DMHC) fined OSCAR $7,500 for violating the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act). Specifically, the OSCAR policyholder went to an in network hospital ER with abdominal pain, received an emergency ovarian cystectomy, and went home the following day. OSCAR later denied the claim for both the emergency and inpatient care. OSCAR’s denial letter failed to provide a complete and accurate account of the reason for its denial. The insurer also erroneously told the policyholder she was responsible for over $900,000 – which was more than fifteen times the amount the hospital actually billed.
In December 2021, the DMHC fined OSCAR $10,000 for failing to assume responsibility for a policyholder’s post-stabilization care in violation of the Knox-Keene Act. Specifically, OSCAR’s enrollee received emergency services from an out-of-network hospital. The hospital contacted OSCAR many times seeking to provide the patient with post-stabilization care. OSCAR denied this care and informed the hospital that a nurse from its “Concierge Team” would contact the hospital to transfer the patient. OSCAR never followed up with the hospital, and the hospital continued caring for the patient. Later, OSCAR covered the emergency part of the claim but not the post-stabilization care claiming this care was not medically necessary.
OSCAR Health Plan of California’s parent company was investigated for wrongly informing those insured under their plan that many of the providers listed as in-network on the provider list were actually out-of-network. This meant that many services, procedures, and tests were denied payment. Not only were claims wrongly rejected, but those insured by OSCAR spent extra time attempting to find an in-network doctor.
In May 2023, OSCAR Health announced it will leave California’s Affordable Care Act-compliant individual health insurance market at the end of 2023 due to poor performance.
When OSCAR Health Plan of California Denies Your Claim, Delays, or Underpays
It can be demoralizing to have your medically necessary healthcare claim denied. You may desperately need a test, a procedure, or a specific prescription medication, yet insurance denies your claim. If you cannot afford to pay out-of-pocket (and most people cannot), where will you turn? You have the right to appeal a decision made by your health insurance company, and Scott Glovsky can help you with just that. At the Law Offices of Scott Glovsky, we can help you manage a health insurance denial by comprehensively reviewing your current health insurance policy, then pursuing all legal avenues to access your right to healthcare coverage.
What Are Common Reasons OSCAR Health Plan of California Claims are Denied?
Perhaps your issue needs to be resolved with a lawsuit claiming bad faith filed against OSCAR Health Plan of California. If insurance denies your claim with no apparent justification, the Law Offices of Scott Glovsky will file such a lawsuit. OSCAR Health Plan of California may deny a claim for many different reasons. There could be an omission of details, clerical error, or billing code mistake. Other times, OSCAR Health Plan of California could deny a claim under the guise of “medically not necessary.” This can be frustrating when your doctor has told you that you need the procedure, the test, or the prescription drug. Sometimes, an insurance company may claim your treatment is too “experimental.” When your treatment is something as simple as a CT scan, an x-ray, or an MRI, being told the treatment is too experimental can be very frustrating.
Should You File an Appeal Against OSCAR Health Plan of California?
If OSCAR Health Plan of California consistently engages in health insurance delays and underpayments or has flat-out denied your claim, it is essential to know that California law mandates health insurance companies must provide timely access to care. Filing an appeal means you ask your healthcare company to review your information and change a coverage decision. A grievance is any complaint about something other than a coverage decision. If you complain about how OSCAR Health Plan of California is treating you, you will file a grievance. It can be overwhelming to file an appeal or grievance on your own because there are ways and dates it will need to be filed. The Law Offices of Scott Glovsky can help guide you to file your appeal or grievance in a way that has a better chance of success.
It is always a good idea to file an internal appeal if OSCAR denies your medical claim. You have nothing to lose and OSCAR may reverse its decision. If OSCAR still refuses to cover your medically necessary care, then you can file an external appeal. An external appeal is called an Independent Medical Review (IMR) in the state of California and IMRs are reviewed by an Independent Medical Review Organization (IMRO). The Department of Managed Healthcare (DMHC) found that 68% of policyholders (across all California plans) who filed IMRs in 2022 ended up getting the medical care that was denied. Looking specifically at OSCAR, of the medical necessity IMRs filed by California policyholders in 2022, 7.9% of denials were upheld, 28.9% were overturned by the IMRO, and 63.2% were reversed by OSCAR. In other words, 92.1% of OSCAR policyholders ultimately received the medical care that was originally denied.
It is important to know that it is very difficult to overturn a Department of Managed Healthcare IMR decision. For this reason, we suggest you speak with a highly experienced health insurance denial attorney before you file one. The attorney may suggest you take a different path. And the path recommended may depend on your health insurance plan type. There are ERISA plans and non-ERISA plans. ERISA stands for the Employee Retirement Income Security Act of 1974 and includes the majority of employer plans. You can learn more about ERISA appeals here and about non-ERISA appeals here.
How the Law Offices of Scott Glovsky Can Help with OSCAR Health Plan of California Delays, Underpays, or Denials
If OSCAR Health Plan of California denied a service, treatment, test, or prescription drug, the Law Offices of Scott Glovsky can help you during this difficult time. We understand that you may be feeling vulnerable, unsure of what you should do next for your health and your future. You may be ill and unable to “fight” with your insurance company, even when it is for something you need desperately. Attorney Scott Glovsky will remove this burden from you, giving you the time to concentrate on your health while he fights for your health, your future, and your rights. At the Law Offices of Scott Glovsky, we will file an appeal on your behalf, create a case before the California Review Board, or argue your case in court. Contact the Law Offices of Scott Glovsky today—we have the experience, knowledge, and skills to go up against OSCAR Health Plan of California—or any large healthcare company.