Where to Turn When You Have Been Denied a Service or Treatment by Your Health Insurer
When you have been denied a healthcare service or treatment—after faithfully paying your insurance premiums for years—you can feel helpless, overwhelmed, and unsure of where to turn. It can be incredibly insulting and demoralizing to discover that the very people you’ve paid to protect you have turned their backs on you. This is not the time to give up. You do not need a legion of lawyers to fight this injustice, you just need one person who cares enough about you and your case to fight on your behalf.
That person is attorney Scott Glovsky of The Law Offices of Scott Glovsky. Scott’s hard-fought case victories have impacted literally millions of insurance policyholders by forcing insurance companies to change their behavior—including their process of reviewing requests for medically necessary treatment and their medical policies. Scott Glovsky can beat your insurance company—just ask Anthem Blue Cross, Blue Shield of California, Health Net, Kaiser Permanente, Aetna, UnitedHealthcare and UnitedHealthcare StudentResources.
In 2016, UnitedHealth joined 11 other health insurance carriers to offer plans in the California State Exchange, however, it was short-lived. By May of 2016, UnitedHealthcare announced they would be leaving the individual market in California—a move that affected about 1,200 California exchange members who were given coverage until the end of 2016. UnitedHealthcare cited “heavy losses” and “Obamacare marketplaces” as their reason for leaving the individual California market. The director of Covered California stated UnitedHealthcare should own up to business mistakes rather than placing the blame on Obamacare. UnitedHealthcare does offer group health insurance plans in California for employers and some varieties of insurance such as Critical Illness insurance to individuals in California.
UnitedHealthcare has the distinction of being the largest single health carrier in the nation, operating as a division of its parent company UnitedHealth Group Inc. The headquarters for United is in Minnetonka, Minnesota. When all subsidiaries and divisions of UnitedHealthcare are counted, the company serves over 52 million members across the United States. UnitedHealthcare states its mission as “helping people live healthier lives and helping make the health system work better for everyone.”
UnitedHealthcare also works with some American universities and colleges to offer health insurance to students. This part of the company is called, UnitedHealthcare StudentResources.
And like its competitors, UnitedHealth Group also owns other health companies. Optum Health has primary, specialty, surgical and urgent care providers and offers in office, at home, and virtual healthcare. In fact, as of November 2023, UnitedHealth Group has approximately 90,000 affiliated or employed physicians which is about 10% of all physicians in the country. OptumRx is the company’s pharmacy benefit manager. In May 2020, Optum purchased NaviHealth, a firm that manages post-acute healthcare services for over 4.5 million Medicare Advantage seniors using unregulated predictive artificial intelligence algorithms. In February 2023, Optum Health added to its portfolio by acquiring home health company LHC Group. Optum Rx offers pharmacy services, and Optum Insight utilizes technology to connect data from various sources to provide insights.
At 29% in 2023, UnitedHealthcare had the largest share of all Medicare Advantage plans. Based on its management of these plans, however, the company has been accused of fraud by the Department of Justice and by internal whistle-blowers. UnitedHealthcare has also been accused of overbilling by the Inspector General.
In 2022, the Department of Justice sued to block UnitedHealth Group’s $13 billion acquisition of Change Healthcare. Change Healthcare manages the biggest data clearinghouse connecting doctors, pharmacies, hospitals and dentists with health insurers to get reimbursed for services provided. The company handles approximately 1.7 billion claims annually. The DOJ thought this acquisition would give UnitedHealth Group a “near monopoly” in certain areas with too much data on its insurance company competitors. In September 2022, a federal judge denied the DOJ effort to block this acquisition. The judge also ordered UnitedHealth to divest Change Healthcare’s ClaimsXten, its claims payment and editing software business. And on October 3, 2022, UnitedHealth Group acquired Change Healthcare.
Also in 2022, a federal arbitration panel ordered UnitedHealthcare to pay $10.8 million for only paying TeamHealth practitioners 30% of what was considered fair compensation from 2017 to 2020. As of December 2022, UnitedHealthcare had paid nearly $500 million in settlements to TeamHealth and there were additional suits pending.
In July 2023, the United States Department of Labor sued UnitedHealthcare’s division that manages employer self-funded health insurance plans (UMR Inc.) alleging it violated the Employee Retirement Income Security Act, also known as ERISA. The federal government, rather than a state, regulates self-funded health insurance plans. The lawsuit alleges that UnitedHealthcare wrongfully denied coverage for both emergency room visits and urine drug tests.
In November 2023, a class action lawsuit was filed against UnitedHealthcare’s parent alleging the company uses an artificial intelligence algorithm to deny Medicare Advantage patients extended long-term care when it knows the algorithm has a high likelihood of error. In fact, denial decisions have been overturned in 90% of appeals. The algorithm is nH Predict developed by UnitedHealth Group subsidiary NaviHealth.
The DOJ opened an antitrust investigation into UnitedHealth Group in October 2023. Although not public, reports in February 2024 claimed investigators inquired about the relationship between UnitedHealthcare (insurance) and Optum health services (owns doctor groups).
When UnitedHealthcare Denies Your Claim
Your health insurance policy with UnitedHealthcare is supposed to provide for you and your family when you are sick or injured. However, all too often policyholders make a claim with UnitedHealthcare only to have their claim denied.
Having a health insurance claim denied can be devastating, forcing some people to forego medical treatment, and leaving some families to struggle with massive medical bills. Unfortunately, health insurance companies such as UnitedHealthcare often deny health insurance claims for baseless reasons such as a belief a treatment is not medically necessary or a refusal to approve a specific procedure in favor of mandating another cheaper course of treatment.
If you were denied health insurance coverage by UnitedHealthcare, you should be aware that you have the right to appeal any decision. Download our eBook on appealing your denial. A Los Angeles UnitedHealthcare health insurance denial lawyer can help you manage a health insurance denial appeal by reviewing your policy and aggressively pursuing your right to health coverage. Contact attorney Scott Glovsky today, and know that you are in capable hands.
Common Reasons UnitedHealthcare Insurance is Denied
If you believe that your insurance company denied your health insurance claim without any justification, you may be entitled to file a bad-faith lawsuit against UnitedHealthcare. Under California Insurance Code §790.03, insurance companies are prohibited from engaging in unfair practices such as “misrepresenting to claimants pertinent facts or insurance policy provisions relating to any coverages at issue.”
Prior to the Patient Protection component of the Affordable Care Act—more commonly known as “Obamacare”—the most common reason why health insurance was denied was that a person had a pre-existing condition. Since the passage of this law, insurance companies such as UnitedHealthcare have turned to other tactics to deny a person health coverage, including but not limited to:
- Clerical errors – health insurance claims or policies can sometimes be denied because of a simple clerical error either on part of the insurance company or the applicant, even though this should not be a determinative factor in denying a claim
- Deeming treatment medically unnecessary – insurance companies often claim that a procedure is not medically necessary, supposedly by having an internal doctor review a claim
- Claiming the procedure is investigational – Insurance companies may legally claim that a procedure is only investigational and therefore refrain from covering it, but they often extend this concept too far and claim that routine practices such as X-rays, MRIs, and CT scans fall into this category
Health Insurance Delays by UnitedHealthcare
UnitedHealthcare and other insurance companies have a duty to provide either prompt payment for a medical procedure or a prompt denial. Furthermore, California law mandates that health insurance companies provide timely access to care. This means that health insurance companies such as UnitedHealthcare must:
- Provide insured individuals access to a primary care provider or to a hospital that is within 15 miles or within 30 travel minutes of their home or work
- Authorize appointments for urgent services that do not need approval within 48 hours
- Authorize appointments for non-services that do need approval within 96 hours
- Provide access to telephone triage or a screening service
- Provide access to a knowledgeable and competent health plan customer service representative in a reasonable amount of time
If UnitedHealthcare insurance company fails to provide these services to you, you can consult a Los Angeles UnitedHealthcare health insurance denial lawyer from the Law Offices of Scott Glovsky who can advise you on how to achieve the results you deserve.
What are the Common Coverage Denials from Health Insurance Providers Like UnitedHealthcare?
Insurance companies like UnitedHealthcare may come up with a myriad of reasons to deny your claim or deny a treatment, service, or prescription medication. All too often, the reason for denial of a claim is simply profit. Insurance companies increase profits by denying claims they judge to be “questionable.” Some of the more common reasons given by companies like UnitedHealthcare include the following:
- There were coding errors for a diagnosis or procedure
- There were omissions regarding a diagnosis or procedure
- Your application was completed incorrectly or incompletely
- You failed to obtain prior authorization or pre-certification before a procedure
- You have provided incomplete insurance information
- You have provided inaccurate insurance information
- You failed to use an in-network provider
- The filing time limit has passed
- You did not supply sufficient evidence of medical necessity
- Your deductible was not paid
- You did not pay your co-pay or patient portion
When your healthcare company denies coverage for a treatment or procedure, it must provide a written explanation that includes information on how the denial can be appealed. A UnitedHealthcare health insurer denial lawyer like Scott Glovsky can help you through the appeal process, which can be fairly complex.
You may have been denied a specific treatment that your doctor believed you needed, or perhaps your insurance company refused to reimburse you for a treatment you already received. Either way, having a highly experienced health insurance denial attorney like Scott Glovsky in your corner can help ensure enforcement of insurance policies.
Appealing a UnitedHealthcare Denial of Coverage
If UnitedHealthcare denied coverage, you have the right to appeal the decision. You must file an appeal within sixty calendar days from the date of the initial decision. This sixty-day limit can be extended for good cause; if you ask for an extension, you must include in your written request the reason why you were unable to file within the sixty-day window of time.
Your attorney can handle the appeal on your behalf, filing your appeal in writing. If waiting for a decision could seriously jeopardize your life, health, or ability to regain maximum function, you can ask for an expedited decision. If you ask for an expedited decision, UnitedHealthcare will issue that decision no later than 72 hours plus 14 calendar days in the event of an extension.
You may have been prescribed a specific drug by your doctor, only to find your insurance will not cover the drug or will only cover a less expensive drug. If the drug is experimental, your insurance company may deny the claim altogether. UnitedHealthcare may require you to start with a less expensive drug (step therapy), and then move up the “tiers” of drugs only when your doctor says the lower tier drug does not work for you. You can appeal such a decision, asking that you be able to use the originally prescribed drug. If you failed to obtain prior authorization for a procedure, UnitedHealthcare could deny your claim. You can also appeal this decision, as well as decisions regarding formulary exceptions, cost-sharing exceptions, or any decision you do not believe is fair.
For standard decisions regarding reimbursement for a Medicare Part D drug you paid for, UnitedHealthcare will provide a decision on the appeal within 7 calendar days of receiving your request. If a decision is not received within 7 calendar days, your request will automatically go to an Independent Review Entity.
FAQs Regarding UnitedHealthcare Coverage Denials
If you have been denied healthcare coverage, you may have many questions, including:
What should I do if a necessary treatment, service, or drug has been denied by UnitedHealthcare?
You have the right to appeal any claim denial from your insurer. While filing an appeal when you are possibly not feeling well can seem overwhelming, your attorney can file your appeals on your behalf. Claim denials are often overturned at the initial appeal level, and if the claim denial is not overturned, you can ask for an external review. At an external review, UnitedHealthcare must abide by any decision made during the review.
My appeal to UnitedHealthcare’s internal review was denied. Do I have to accept this decision?
You do not have to accept the initial denial of your appeal. You have the right to a third-party external review, and if your initial appeal is denied, you should definitely try this route. Your health and well-being are worth the effort required during the appeals process.
What should I do if I don’t understand why my UnitedHealthcare claim was denied?
UnitedHealthcare may have denied your claim because it believes your condition to be pre-existing, because you used an out-of-network provider, because the treatment is considered experimental or because the company does not believe the treatment is medically necessary. You may be required to prove that the denial has no merit, which may require assistance from your health care team.
News Related to UnitedHealthcare
Unfortunately, in February 2020, UnitedHealthcare was ranked among the top ten worst insurance companies in America by the American Association for Justice for its bad faith insurance practices. UnitedHealthcare was accused of misrepresenting its products in 2007 and fined by a number of states for denying and delaying claim payments. UnitedHealthcare has continually been accused of putting profits over people, namely its policyholders. In one survey, a full 65 percent of UnitedHealth policyholders said they were very dissatisfied with their insurers, and only 8 percent said they were extremely satisfied with their insurer.
- Loma Linda University Health Care Medical Group (through UnitedHealthcare) Denied Medically Necessary Electric Wheelchair to Member with Amyotrophic Lateral Sclerosis (ALS)
- We filed this case against UnitedHealthcare that resulted in the insurer overturning its denial of medically necessary ulcerative colitis biologic medications.
How Scott Glovsky Can Help if You’ve Had a Coverage Denial
Most people expect their insurance to come through for them when they really need it—particularly their health insurance. After all, you pay your premiums each and every month, so to have a necessary treatment, service, ER visit, or drug denied can be very disheartening. Further, when you are ill, you simply may not feel up to a fight with an insurance company. Scott Glovsky can take that fight on for you. Scott is a UnitedHealthcare health insurance denial lawyer you will be glad to have in your corner when it comes time to fight the insurance company.
Scott can file your initial appeal with UnitedHealthcare, create a case before the California review board, or take your case to court to ensure the policy is enforced. If UnitedHealthcare denied your health insurance claim, contact Scott Glovsky today to get the help you need and deserve. Scott will make sure you get the treatment you need while making sure UnitedHealthcare delivers the coverage you were promised. Scott will never hesitate to go up against a large insurance company—he’s been doing just that for over two decades. When you want a good outcome to an insurance claim denial, contact Scott Glovsky.