Health Insurance Claim Denials

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Los Angeles Health Insurance Denial Attorney

Page Contents:

Experienced Health Insurance Claim Denial Lawyer Serving Claremont and Pasadena
What Are the Legal Duties of an Insurance Company?
Why Are Claims Often Denied?
How Do Insurance Companies Manage to Deny, Delay, and Underpay?
What Rights Do You Have When Your Claim Is Denied?
What Is the Role of a Lawyer When Your Health Insurance Claim Is Denied?
What Are Some Common FAQs Regarding Health Insurance Claims Denial?

Scott literally wrote the book on fighting health insurance denials! Schedule a free consultation with our Los Angeles health insurance denial lawyer today by calling (626) 323-8351 or contacting us online.

Experienced Health Insurance Claim Denial Lawyer Serving Claremont and Pasadena

When you have spent years paying health insurance premiums only to have a claim denied, it can be very discouraging, not to mention potentially damaging to your health. You may need to fight for your rights when it comes to a health insurance denial so you can receive the treatment you need. Most people have no idea where to start or how to proceed when fighting a health insurance denial. Moreover, fighting a big, impersonal insurance company to receive necessary treatment can be a difficult journey that many are simply not up to. When your health is at stake, it is important that you choose an insurance bad faith attorney like Scott Glovsky—a nationally recognized advocate for the rights of the injured and insurance policyholders.

At the Law Offices of Scott Glovsky, we help individuals and businesses get the services, benefits, and compensation their insurance company promised to provide. Whether your claim denial involves health insurance, business insurance, homeowners’ insurance, general liability insurance, auto insurance, long-term care insurance, or any other type of insurance policy, Scott Glovsky can help. Scott knows every tactic practiced by insurance companies, including the most common: delay, deny, underpay. The consequences of these tactics can range from merely inconvenient to catastrophic. For information on fighting health insurance denials, download our eBook, “Everything You Need to Know About Fighting a Health Insurance Denial.”

When you are choosing an attorney to help you fight this injustice, don’t you want one who knows the insurance industry inside and out? Scott Glovsky is that lawyer. Scott spent the first phase of his career defending large insurance companies against allegations they improperly handled claims. While attorney Scott Glovsky worked on many of these lawsuits, he simply did not enjoy defending these large insurance companies, feeling they used questionable reasons for denying, delaying, and underpaying claims. Scott found himself sympathizing with the policyholders and was moved by how their lives were turned upside down.

Scott began representing policyholders instead of insurance companies in 1999 and has consistently sought justice for his clients in ways other firms cannot. Scott is passionate about helping policyholders obtain treatments, coverage, and reimbursement from California insurance companies, including Aetna, Anthem Blue Cross, Blue Shield of California, Health Net, Kaiser Permanente UnitedHealthcare, and other companies providing insurance.

What Are the Legal Duties of an Insurance Company?

Your insurance company has certain basic responsibilities owed to you, the insured. If these responsibilities are not upheld, the insurance company could face liability for the resulting damages. The duties of insurance companies include:

Duty to Defend

When a third party brings a claim, the insurance company has a duty to defend its policyholder, hiring an attorney at its own expense to properly represent the policyholder by providing a meaningful defense. This is a broad duty, extending to all claims potentially covered under the policy, based on any facts alleged or otherwise disclosed in the claim. The courts have held that a meaningful defense includes all claims and does not allow an insurance company to parse claims.

Duty to Indemnify

When written and specified in contracts, indemnity can be confusing. In its simplest form, indemnity refers to the obligation of one party to pay for losses incurred by another party. As an example, as a policyholder, if you are found liable to a third party for damages, your insurance company must pay the damages up to the policy limits. This payment is called indemnity.

Duty of Good Faith and Fair Dealing

The relationship between an insurance company and a policyholder creates a duty of “good faith and fair dealing,” with the courts often referring to what a policyholder is really buying as “peace of mind.” The insurance company must do what is right to protect the policyholder—if they do not, they could be acting in bad faith. This bad faith can trigger severe penalties for an insurance company, including the possibility of punitive punishment.

Duty to Fairly and Quickly Manage Claims

Insurance companies have a duty to fairly and promptly investigate any first-party and third-party claim, to provide the benefits of the policy, and to pay any valid claim. These duties must be carried out with reasonable speed under the insurance company’s duty of “good faith and fair dealing.”

Duty to Settle Within Insurance Policy Limits

Recent California law indicates insurers must make a good faith effort to settle a claim within its own policy limits, regardless of whether or not the other party demands a settlement. Failure to do so can indicate bad faith on the part of the insurance company.

Duty to Disclose Conflicts

Insurance companies have a duty to disclose any conflicts that occur during the case to the insured. The defending attorney has a duty to equally weigh the interests of both the policyholder and the insurance company, and when a conflict arises, the defense attorney must disclose to both. In some cases, a separate attorney for the insured (paid for by the insurance company) could be required. This is known as Cumis counsel.

An example of a conflict that would trigger Cumis counsel is when the defense lawyer uses policy limits as the upside risk to the insurance company while risking harm to the policyholder by doing so. Obviously, the insured wants the defense attorney to aggressively settle the claim within the limits of the policy since any amount over the limit would be the insured’s responsibility. The conflict arises if the defense attorney knows there is a good chance of losing the case yet attempts to minimize the settlement by threatening trial.

Another common conflict occurs when an insurer believes certain claims are not a part of the policyholder’s coverage, issuing a “reservation of rights” letter which states the insurance company is reserving the right to later deny the claim, should any facts surface that prevent coverage. Such conflicts could result in the defense developing a strategy that harms the insured, based on how the claims in the case are addressed and defended. In the state of California, when an insurance company issues a “reservation of rights” letter, it may be acknowledging a conflict that allows the insured to hire a separate attorney.

Any time a conflict prevents the insured from receiving a proper defense, the insurance company must hire and pay for a separate lawyer to defend the policyholder. The Cumis counsel—the attorney representing a defendant in a lawsuit where there is an insurance policy covering the claim, but there is a conflict of interest between the insured and the insurance company—can lead to a better defense for the insured. Attorney Scott Glovsky has litigated many cases where Cumis counsel should have been appointed but was not. In this type of situation, the insurance company must pay damages caused by the failure to provide Cumis counsel.

In short, insurance companies have the following obligations to their policyholders:

Insurance companies must treat the interests of those they insure with the same consideration given to their own interests.
Insurance companies must help policyholders with claims, explaining coverage and available benefits to those they insure.
Each claim must be promptly and fairly investigated by the insurance company.
When payment is owed, the insurance company must promptly pay the claim.
If a claim is denied, an explanation must be given to the insured by the insurance company.
All significant facts associated with the claim must be disclosed to policyholders.

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Why Are Claims Often Denied?

When an insurance company refuses to pay a health care claim, it is known as a denial. Some of the most common reasons (according to healthcare insurance companies) your healthcare claim could be denied include:

Often, claim denial is the result of a mix-up or paperwork error. As an example, your name could be listed differently between your doctor’s office and your insurer, such as Jane Q. Doe vs. Jane O. Doe.
The insurance company does not believe the requested service is medically necessary, even if you need the service. Your healthcare provider must then provide more information regarding why you require the medical service.
The insurance company wants you to try a different (translate: less expensive) option first. In some cases, if you do try the less expensive option first and it doesn’t work, then the insurance company will pay for the requested service. Prescription drug step therapy is a common example of this. Statin drugs are very expensive, some even more than others. Your doctor might prescribe a statin that is at the high end of the spectrum. The insurance company may require you to try less expensive alternatives, then if your doctor states those alternatives did not work, the original prescription could be covered.
The health service you are requesting isn’t covered by your healthcare plan. As an example, many healthcare insurance policies do not cover cosmetic surgery, some policies will cover chiropractic care while others will not, and some policies will cover mental health expenses, while others will not.
Your medical services were not administered by an in-network healthcare provider. Managed care systems tend to be very structured, allowing you to seek treatment only by doctors and facilities that are part of your plan’s provider network. If you are seeking prior authorization for a medical treatment from an out-of-network provider, you might be approved for the treatment from an in-network healthcare provider.
There are details missing from your claim or pre-authorization request. Your healthcare provider may not have provided sufficient detail regarding why you need the treatment or procedure.
The rules of your health plan were not properly followed. As an example, say you are required to obtain pre-authorization for a specific non-emergency test, yet you have the test done without getting pre-authorization. The insurer may then deny payment for that test, even if you really needed it, simply because you failed to follow the rules.

You may wonder how often claims are denied. In 2020, about 18% of in network claims were denied (claims and appeals for non-group qualified health plans offered on the healthcare.gov exchange) according to the Centers for Medicare and Medicaid Services (CMS). This 18% is an average. Individual insurance company denial rates varied from under 1% to over 80%. And less than 1% of people appeal these decisions.

How Do Insurance Companies Manage to Deny, Delay, and Underpay?

Health insurance companies routinely find “loopholes’ in their policies as a method of minimizing payouts. You may wonder just how insurance companies manage to get away with the deny, delay, underpay tactics, and how those tactics are implemented.

Deny

Insurance companies may deny claims for a variety of reasons, perhaps by claiming the premiums were paid late, or that a policy excludes certain coverage. Regarding healthcare denials, the following are the most common reasons for denials:

The medical treatment or procedure is not covered, is not medically necessary, was not pre-authorized, or is experimental.
The procedure denied is merely cosmetic.
The medical provider was out-of-network, or out-of-plan.
The policyholder misrepresented something in their original application.

Attorney Scott Glovsky has often achieved reversals of denials for any of the above reasons.

Delay

Insurance companies are well-known for coming up with one excuse after another for not paying benefits for health insurance claims as well as for homeowners or other loss incident claims. At a time when you need the insurance you paid for desperately, your insurance company may delay claim approval to the point where you simply give up. Those insured are often given the following excuses for healthcare coverage delays:

The insurance company claims it never received the proper paperwork.
The insurance company claims it is waiting for an evaluation from a medical professional.

Attorney Scott Glovsky never gives up on his clients and will fight for an approval as long as there is even a shred of hope.

Underpay

When a claimant is desperate for financial relief following a loss, the insurance claims reviewer may feign compassion and helpfulness, with a result of a low settlement or lower-than-expected payout. Those who have already been through the deny and delay stage may accept the underpayment out of sheer exhaustion, and because any financial relief is better than none. Healthcare insurance companies may do the following to underpay a claim:

The insurance company may offer to pay for a lower-cost treatment or procedure.
The insurance company may offer partial reimbursement.

Attorney Scott Glovsky will fight for your rights when your insurance company wants to underpay you for your claim. Insurance companies underpay because they can; we can stop this type of behavior.

What Rights Do You Have When Your Claim Is Denied?

When an insurance company acts in bad faith or breaches your insurance contract, and you incur damages as a result, you have the right to sue the insurance company and recover those damages. If your health insurer refuses to pay a claim or ends your coverage, you also have the right to appeal that decision, asking for a third-party review. Your attorney may ask the insurance company to reconsider its decision—not only do insurers have to tell you why your claim was denied, they also have to let you know how you can dispute a denial. You have the right to an internal appeal, within the insurance company, where they are asked to conduct a full and fair review of the denial. You also have the right to an independent third-party review, known as an external review. This means the insurance company no longer gets to say whether they will pay a claim.

If your insurance company breaches your insurance contract or acts in bad faith, and you incur damages, the Law Offices of Scott Glovsky can help. You can call (626) 323-8351 or complete the contact us form for a free consultation. Denials, delays, or underpayments made for bad reasons constitute not only an injustice—the insurance company is breaking the law. If an insurance company breaches this covenant, the policyholder may sue the company on a tort claim (for bad faith) in addition to a standard breach of contract claim. Under tort law, the plaintiff may recover punishment/punitive damages – damages to deter wrongful conduct.

The specific duties of an insurance company vary by type of claim (“first-party” or “third-party”) and coverage (health, property, life, etc.). Generally, an insurance company must have policies and procedures in place to review and pay claims. It must investigate claims, determine coverage, and pay proper values. It must follow applicable laws and regulations. When it violates one or more of these, it may be acting in bad faith. The Law Offices of Scott Glovsky is based in Pasadena and Claremont in the Los Angeles region but works with policyholders all over California ensuring that insurers pay for claims and provide the treatments and services that its policyholders need and deserve.

Why Should You Hire Scott Glovsky as Your Los Angeles Health Insurance Denial Attorney?

Attorney Scott Glovsky is happiest when fighting for justice against big corporations who often believe they are untouchable. When major corporations drag you to a low point in your life, Scott will step in to make a positive difference. You may have been left injured, ignored, depressed, anxious, and stressed about your future. Scott Glovsky will immediately let you know you are no longer in this fight alone. Scott fights for justice for you—and for each and every client—with his heart and soul, always staying fully committed to your case.

When justice has become elusive, Scott Glovsky could be your last chance to obtain the justice you deserve. If your health insurance company has denied you medically necessary treatment, canceled your insurance, denied benefits to you because you are a senior, or simply chose to underpay on legitimate claims, the Law Offices of Scott Glovsky will seek justice for you in ways other firms cannot—or will not.

Unlike other firms, The Law Offices of Scott Glovsky purposely takes few cases, so Scott can be personally attentive to each and every client and case that is being handled by the firm. From the start, Scott and his team are in the fight with you, listening to your needs and goals, to determine the right next step. With Scott, you can be sure that you will not be another case number, but you will be heard and justice fought for you.

Los Angeles bad faith lawyer Scott Glovsky has been nationally recognized as a strong advocate for the rights of the injured and insurance policyholders. People Magazine, CNN, CBS, and The Oprah Winfrey Show have all featured Scott Glovsky’s clients in stories regarding those in need of critical medical treatments and procedures who have faced insurance company injustice. Millions of Los Angeles and Southern California patients have gained access to behavioral therapies, thanks to attorney Scott Glovsky’s insurance bad faith class action lawsuits against health insurance companies.

Mr. Glovsky has received numerous awards for his work, including the California Lawyer Attorney of the Year Award, Consumer Attorneys Association of California’s “California Street Fighter of the Year” award and the “President’s Award of Merit” from the Consumer Attorneys Association of Los Angeles. Contact the Law Offices of Scott Glovsky today to get the justice you need and deserve.

You owe our firm no legal fees unless we win, so don’t wait to schedule a free case evaluation by calling (626) 323-8351 or contacting us online. Se habla español.

What Are Some Common FAQs Regarding Health Insurance Claims Denial?

What are the steps in the appeals process?

In brief, the appeal process steps include the following:

You file a claim for benefits coverage or pre-authorization.
Your health plan denies your claim.
You file an internal appeal, requesting your insurer to reconsider its decision to deny your claim.
Either the issue is resolved, or your insurer continues to deny your claim.
If your claim is denied at the internal review stage, you can request an external review.
The external review either upholds or overturns your insurer’s decision to deny payment.

What is an internal appeal?

An internal appeal is the action taken when you disagree with your insurer’s decision regarding coverage or payment for a treatment or procedure. By filing an internal appeal, you are asking your healthcare insurer to reconsider its original denial. If your situation is urgent, you have the right to request an expedited review.

How long does an internal appeal take?

You have 180 days to file an internal appeal from the date of your original denial. The internal appeal must be completed within 30 days of your claim for a pre-service claim, or within 60 days of your request if the service has already been received. Your insurer must provide you with a written decision, whether it agrees to pay for the service or continues to deny the service.

What is an external appeal?

If your internal appeal is denied, you have the right to request an external appeal. An organization that is independent of your health insurer will conduct an external review of the denial. The organization will either uphold the decision made by your insurer or will decide in your favor via overturning some or all of the original decision made by your healthcare insurer. Your insurer is required to accept the decision following an external appeal or review.

How long does an external review take?

A standard external review will be decided as quickly as possible, but no later than 60 days after receiving your request for an external review. If your situation is urgent, you can request an expedited review. In the case of an expedited review, a final decision must be made as quickly as your medical condition requires, but at a minimum, four business days after receipt of your request. The decision can be delivered verbally but must be followed up with written notice of the decision within 48 hours.

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"Scott reviewed my case and the appeal documents I sent to him, and called me right on time to give me a free consultation."
He had some good advice about appealing a denial of coverage from Kaiser Permanente, and my options if the appeal is denied. Thanks, Scott!

- Paul A.
"Scott was the only one who paid attention to our case, and the only one who felt that could help us with an insurance case."
He talked to us personally, and gave us all the attention we needed. Finally he made the health insurance to pay the service they were denying us and we even got a compensation for it. Don’t hesitate, and call them.

- Emi S.
"Scott is hands-down one of the best plaintiff attorneys in Southern California. His expertise is unquestionable."
He truly cares about his clients and his cases. I have worked with Scott professionally for the last eight years and don't hesitate to refer friends, family, and others to him when they need legal help. You simply won't find an attorney who's better.

- Stephen D.

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