Not every medical cost is foreseeable. Many times, a person has a medical emergency while traveling. When this happens, they may be forced to seek medical treatment while out of their insurance company’s network. This can result in the insurance company refusing to pay for any treatment provided by the out-of-network provider or agreeing only to pay at a reduced amount, leaving a patient with thousands of dollars of medical costs that they will be required to pay.
However, there may be legal avenues to demand that an insurance company covers out-of-network costs associated with necessary medical treatment. A Los Angeles out-of-network coverage denial lawyer can help denied subscribers choose the path forward that gives them the best chance of obtaining payments for their treatment. Work with a capable health insurance denial attorney that could work towards a positive outcome for you.
When is Medical Treatment Out-of-Network?
All health insurance providers in Los Angeles have an established network of doctors, hospitals, and other healthcare providers. These are parties with which the insurance company has an established relationship and an understanding concerning payments for treatments.
Depending upon the type of insurance plan, insurance companies can require their subscribers to obtain treatment from providers that are within their network. If a person seeks treatment from an out-of-network provider, the insurance company may refuse to pay or pay at a reduced rate. This commonly occurs as the result of an emergency. For example, if a person is out of state visiting family and is injured in a car accident, they may travel to a local hospital as a matter of necessity and receive care from an out-of-network provider.
Out-of-network issues can also arise out of a person’s voluntary choice of providers. For people with rare, specific conditions, only a few doctors may be able to provide the best treatment. This can force a person to choose an out-of-network provider to receive the treatment they need. In either instance, a health insurance company may choose to deny payment. For more information, contact a Los Angeles out-of-network coverage denial lawyer today.
Steps to Appeal a Denial in Los Angeles
Anytime that a health insurance company denies coverage, they must state their justification for doing so in a written letter. For instance, if they refuse to pay for treatment received at an out-of-network provider, their denial letter must specifically state this fact. California law gives anyone who receives these letters at least 30 days to file an appeal with their insurance company.
These appeals can argue that the treatment was medically necessary as an emergency treatment or that the provider of the care was the only potential option for the specific condition. Still, these internal appeals are rarely successful.
To obtain relief, people can act with the State of California. This can include filing an appeal with the Department of Managed Healthcare (DMHC). This agency is dedicated to examining health insurance coverage denials and consists of independent doctors who evaluate every denial on a case-by-case basis. There are risks to filing an appeal with the DMHC and you should consult with a Los Angeles out-of-network coverage denial lawyer before making such a decision.
People may also take their case to court. A health insurance policy is a contract that insurers are bound to uphold. If they refuse to issue payment that could be reasonably construed to be included in the policy, this may be a breach of contract. A civil case in California alleging breach of contract may be some subscribers’ best chance to obtain payments.
How a Los Angeles Out-of-Network Coverage Denial Attorney Could Help
Few experiences in life are as disheartening as being denied necessary medical care. Whether a denial happens before the care is received or happens when the time comes to pay for emergency services, this can have a profound impact on a person’s life.
One common reason for a denial is that the provider was out-of-network. While this is a seemingly ironclad reason for a denial, an experienced Los Angeles out-of-network coverage denial lawyer may be able to help. These attorneys work with individuals to understand the reason for the denial and to determine what arguments against the denial are available. Contact our office today to schedule a consultation.