Scales of Justice

Health Insurance Denial

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We get health insurance to help control the outrageous expenses we face not only in the event of an injury or sickness, but even as a product of routine exams and procedures necessary to maintain health. Whether we select the policy ourselves or it is provided through our workplace, we are all given the impression that it will take care of us in the face of high medical costs.

But often we find that our coverage was misleading, or something that seems it should be covered is inexplicably denied. In these cases, you should not (and many times simply cannot) absorb the cost of these procedures in your own budget. You must hold your insurance company responsible for the full coverage promised to you.

Most health care plans have an appeals process and, in general, you must file an appeal before you are allowed to file a lawsuit. However, this does not mean you should not contact a lawyer at this time. Often, the way you present your appeals case can have a profound impact on the ultimate outcome of any lawsuit you might file. In order to make sure your appeal is properly handled by your health insurance company:

  • Read the description of the appeals process in your policy and make sure you file your appeal in a timely fashion
  • Put your complaint in writing. Be as detailed and specific as possible and be sure to state that
    • 1.The procedure is medically necessary
    • 2.You are seeking it on the recommendation of your recognized physician
    • 3.The procedure should be covered based on the terms of your policy
  • Keep tabs on your appeal to make sure it is being handled in a timely fashion
  • Keep a record of all communications between you and your insurance company

If you do these things, you will be adequately prepared to go to trial should your appeal be denied.

If you do go to trial, know that judges are highly inclined to interpret the language of your policy in favor of coverage. This is because the insurance company has the power to write the policy, so there is no excuse for misleading or deceptive language.

If you have been victimized by your insurance company’s denial of coverage, don’t let them get away with it. Medical coverage is too expensive and too important to let insurance companies profit without responsibility. Contact us at Carr & Carr today for a free case evaluation.

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