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In 2017, a kff.org report revealed that nearly one in five claims submitted for an in-network service were denied among Marketplace plans. Unfortunately, enrollees only appealed a fraction of those denied claims. There was a significant variation in denials from one insurer to the next; some had a denial rate as low as one percent, while others had an in-network denial rate as high as 45 percent.
Denial rates also varied considerably from state to state. Like most people, you probably went through a long process to find the best insurer and policy for you and your family. This generally involves carefully going over benefits and coverage to determine whether this insurance company can meet your needs. When your health insurance company denies a legitimate claim or engages in delay and underpayment tactics, you need help in the form of a San Diego health insurance denial attorney.
The mission of Attorney Scott Glovsky and his legal team is to help those who an insurance company has wronged. We care about you, your issue, and your future. We will always listen to you, be available to you, put your needs first, and support you to the fullest extent. We will treat you with respect and dignity while fearlessly and aggressively fighting for your rights.
At the Law Offices of Scott Glovsky, we only take cases we fully believe in, and we promise to expose wrongdoing to make the world a better place. We are always fully prepared—we win through exposing the truth. Attorney Scott Glovsky never hesitates to go up against a giant insurance company because that is what he does, and that is what he believes in.
What are the Legal Duties of Your San Diego Insurance Company?
When you purchase health insurance and faithfully pay your monthly premiums, it may never occur to you that at a time when you need your insurance company the most, it may turn its back on you. There are certain things you can legally expect from your insurer, including being treated fairly and not taken advantage of. Other legal duties of your insurance company include:
- Your insurer has the legal duty to deal with you—and every insured member—fairly and in good faith. This means your insurer must abide by all contractual obligations as outlined in your policy.
- Health insurance companies must ensure all necessary information is accurately and honestly communicated to their customers. Health insurance companies are not allowed to misrepresent any facts regarding your policy, including those associated with benefits and coverage. Your insurer must also communicate with you regarding your rights as a policyholder.
- Possibly the most important legal duty your health insurance company has is to investigate any claim by an appropriately insured. All necessary information must be obtained, including medical records and all relevant documents from your healthcare provider. In other words, your insurer cannot simply deny your claim without an investigation.
- If your insurance company denies your claim, it must provide a valid reason for doing so.
- Once your claim has been denied, you have the right to appeal that decision if you believe it is wrong or unjust. Insurance companies must allow such appeals and provide policyholders with information regarding how to appeal a denial or partial denial.
- When your appeal has been submitted, your insurer must respond within a specified length of time.
What are Health Insurance Bad Faith Practices?
Although insurance companies have to act in good faith toward their policyholders, the company may fail to do so in some cases. This means the insurer is acting in bad faith toward a policyholder. Some examples of insurance bad faith practices include:
- Failing to answer claim questions promptly by delaying responses.
- Changing details of a policy without informing policyholders.
- Failing to provide a full payment amount as described under the insurance policy.
- Not engaging in a proper investigation.
- Failing to process a claim.
- Misrepresenting coverage information, benefits information, or policy information.
When your insurer engages in bad faith practices, your rights as a policyholder are being violated. You do have options, and these options can best be put into place when you have an experienced San Diego health insurance denial attorney from the Law Offices of Scott Glovsky in your corner.
Why Do Health Insurance Companies Deny Claims?
A health insurance company could deny your claim for a valid reason or for a reason that indicates bad faith. Valid reasons for denial of benefits include:
- You failed to obtain a pre-authorization for a procedure or specialist
- The services or procedures are not covered under the terms of your insurance policy
- The insurance company considers the procedure you need to be cosmetic, experimental, unnecessary, or investigational.
- Your chosen physician or provider is not within your policy’s network
- You failed to submit all the necessary details or documents
What are the Most Common Tactics Used by Insurers to Delay, Deny, and Underpay?
When insurance companies are acting in bad faith, they may deliberately delay or underpay a claim or deny it without properly investigating. Delaying payment is a tactic meant to make you eventually give up out of sheer exhaustion. Insurers are required to pay all valid claims in a timely manner, as per your policy. An insurer may ask for unnecessary documentation as a means of delaying your claim or could fail to offer any explanation for the delay. Delaying claims allows the company to hold on to their money a little longer, but this is a bad faith practice.
Denials of insurance claims for no valid reason can be considered a breach of a fiduciary indemnification contract. In the simplest terms, your insurance company cannot deny a claim that falls within the terms of your policy so long as you have met your own obligations (like paying your monthly premiums). If your insurance company has unreasonably denied your claim, bad faith damages could potentially be awarded. Finally, insurance companies may deliberately underpay a claim, particularly if you have been in a struggle to convince them to pay it in the first place. They are counting on the fact that you will be so relieved to get any amount that you will not question the underpayment.
How Can Speaking to a San Diego Health Insurance Denial Attorney from the Offices of Scott Glovsky Make a Difference?
When you are at the end of your rope with your insurance company, do not give up! Instead, contact Attorney Scott Glovsky, a highly experienced San Diego health insurance denial attorney, to determine your best course of action. Scott will always be honest and straightforward with you, helping you receive payment for your denied claim. We strive to help those who have been wronged, and we care about the outcome of your claim. While fearlessly and aggressively fighting for your rights, health, and future, we will also always treat you with the respect and dignity you deserve. If results matter, then hire the Law Offices of Scott Glovsky.