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How to Fight A Health Insurance Denial

Posted Friday, November 2, 2018 by Pivotal Law Group

Many Americans increasingly find themselves dealing with huge medical bills after medical procedures their health insurers should have covered. All too often, the insurance company says "it's not our problem, talk to the hospital;" the hospital says "it's not our problem, talk to your insurer;" and the insured is left holding the bag, often at a time they're already dealing with the stress of major surgery or illness.

The good news is Washington insureds have specific rights they can enforce to hold their health insurer accountable. Insurers must follow the specific terms of the policy contract and cannot deny coverage for medical bills without a reasonable basis. If insurers fail to live up to their obligations, the insurer has legal rights under Washington's Consumer Protection Act and Insurance Fair Conduct Act, or the federal Employee Retirement Income Security Act, to seek a court order requiring coverage and requiring the insurer to pay the insured's attorney's fees.

Unfortunately, fighting a health insurance denial takes significant time and effort, which can be hard when you're already recovering from surgery or illness. This is why many health carriers have been criticized for making the process difficult and confusing in the hope that insureds will simply give up without fighting the denial.

There are three common reasons why health insurance claims are denied:

  1. The insurer determines the procedure, treatment or medicine was not "medically necessary." The definition of "medically necessary" depends on the specific policy, but, generally, when the insurer says the procedure wasn't medically necessary they basically mean "we don't believe you really needed it." Sometimes the insurer uses the same rationale to deny coverage on the basis the treatment is supposedly "experimental."
  2. The hospital or doctor who provided the treatment was out-of-network, meaning the provider didn't have a contract with the insurance company. Most health insurance severely limits or eliminates coverage for out-of-network providers.
  3. The doctor or hospital who provided the care used improper billing and coding, causing the insurer to reject coverage because the hospital didn't properly detail what care was performed.

The good news is many people successfully fight their health insurer's denial of coverage. Each of the three common reasons health claims are denied can be subject to attack:

  1. Denials on the basis treatment was not medically necessary can often be fought with the support of the doctors who prescribed the treatment or care at issue. Too often, health insurers misread, gloss over, or outright ignore a physician's rationale for prescribing treatment. Especially where treatment is expensive or time consuming, insurers have a powerful temptation to "miss" the medical records demonstrating the patient needs the treatment in order to justify denying coverage for treatments that will cost the insurer a lot of money.
  2. Denials for out-of-network treatment can be fought by insisting the insurer follow the policy contract and the federal Affordable Care Act (a/k/a Obamacare). Often, the policy contract requires the insurer to provide at least some degree of coverage even where the treatment is out-of-network. Furthermore, if the insured was treated by an out-of-network provider for emergency care, the Affordable Care Act requires the insurer to treat the care as though it was provided in-network.
  3. Improper billing and coding by the hospital can often be challenged by a thorough review of the medical records, procedure codes and billing codes.

Importantly, your insurer cannot deny health care coverage without a reasonable explanation. This means you have the right to know specifically why coverage was denied and to get the information you need in order to fight the denial. Most health insurers are required to allow you to "appeal" the denial before filing a lawsuit.

Lastly, in fighting a health insurance denial, be mindful of the applicable deadlines. All health insurance disputes are subject to deadlines that will cause the insured to lose their right to challenge the health coverage denial if the insured fails to act within a certain time period. The specific deadline varies, so it is critical to be diligent and stay aware of any applicable deadlines when fighting a health coverage denial.

Pivotal Law Group attorney McKean J. Evans represents insurance policyholders and has obtained favorable outcomes in disputes with insurance carriers in health care and other insurance disputes. If you have questions regarding a health insurance or other insurance coverage matter, contact McKean for a free consultation.