Circumstances of Los Angeles Insurance Denial

An insurance company’s goal is to make a profit. This is why they may refuse to provide coverage for some people and certain treatments. Also, it is not uncommon for insurance companies to illegally deny coverage for medical treatment. If they illegally denied you coverage, you may want to obtain a seasoned health insurance denial lawyer who could help you file a claim. An experienced attorney will be knowledgeable of the different circumstances of Los Angeles insurance denial.

Treatment Not Considered Necessary

Insurance companies often deny coverage to policyholders in Los Angeles in the context of health insurance for treatment not being medically necessary. This allows them to avoid potential liability for class actions because determining whether treatment is medically necessary for one person is a specific evaluation that generally does not apply to other people.

This is a way for health insurance companies to insulate themselves from liability for denying a common treatment to many of their members. Health insurance companies like Anthem Blue Cross, Blue Shield, Aetna, Kaiser, and UnitedHealthcare also deny treatment based on a claim that a treatment is an experimental or investigational treatment. There are many cases where health insurance companies claim that treatment approved by the FDA is not covered because it is experimental or investigational. This is a wrongful action by the insurance company because a treatment that is medically necessary for a patient and approved by the FDA is almost never investigational or experimental.

Pre-Existing Conditions

Another one of the circumstances of Los Angeles insurance denial is when the insurance company claims that the policyholders failed to disclose pre-existing conditions. Under Obamacare and in other specific situations, insurance companies cannot deny treatment based on pre-existing conditions. However, some insurance policies still deny treatment based on a pre-existing condition, fraud, or failure to disclose the pre-existing condition.

Insurance companies are charged with a duty of knowledge of information and they would have learned had they investigated the information disclosed on the application. If an applicant lists the name of a physician who treated them for a certain disease, the insurance company is charged with the information and would have discovered had it investigated the physician’s records and treatment.

Rights of a Person Following an Insurance Claim Denial

A person has the right to obtain all the relevant documents outlining the circumstances of Los Angeles insurance denial and the right to receive the information on which the denial was based. They also have rights under California law to be advised of all policy provisions that apply to their claim as well as the insurance company’s obligations under the Fair Claim Settlement Practices Act for health insurance that is denied based on treatment being not medically necessary.

People have a right to receive information in the denial letter. Specifically, treatment that is denied as not medically necessary must include a written denial letter that provides a clear and concise explanation of the reasons for the decision, a description of the criteria or guidelines used in the decision, the clinical reasons for the decision to deny treatment as not medically necessary, and information about the patient’s right to appeal the denial.

Denial of Coverage for Out-Of-Network Treatments

Insurance companies sometimes deny coverage for certain treatments as being out-of-network. Under many Prefered Provider Organizations and almost all Health Maintenance Organizations and Exclusive Provider Organizations, insurance companies deny treatment as out-of-network if the treatment is not provided by an in-network healthcare provider. Insurance companies have a legal duty and obligation to allow a member to go out-of-network for treatment when the insurance company cannot provide the appropriate treatment within its network.

It is common that individuals with rare or unusual diseases need to go out-of-network for appropriate medical treatment. But some insurance companies resist allowing patients to go out-of-network because it costs them more money. Before any patient goes out-of-network, they should contact their health insurance company and provide a written explanation of why they must go out-of-network to get appropriate medical care.

Bad Faith Cases in Los Angeles

Court cases for insurance denials are usually long and document-intensive. Insurance companies keep files relating to each claim and every request for medical treatment, which is a requirement under California law. These cases can involve thousands of pages of documents. Because insurance companies often deny claims systemically in bad faith cases, policyholders can obtain pattern and practice discovery.

In health insurance bad faith cases, the relevant industry guidelines often include the National Committee for Quality Assurance (NCQA) and URAC, a nonprofit healthcare accreditation organization. Health insurance bad faith cases also involve expert testimony relating to how the denied medical treatment damaged the member or patient.

If your insurance company has denied you coverage, call a compassionate lawyer who is well-versed in the circumstances of Los Angeles insurance denial. An attorney can hold your insurance company accountable.