Health Insurance

By the attorneys of DI Law Group

Contents:

Health Insurance Coverage Claim Denials

Health insurance policies are often written with ambiguous coverage terms that render it difficult for individuals to understand whether a treatment or procedure is covered and easy for insurance carriers to wrongfully deny claims. Unfortunately, patients often learn that their insurance carrier will not honor its commitments under the policy and approve the needed medical or psychological treatment which their healthcare professionals have recommended. The attorneys at DI Law Group understand the importance of receiving appropriate healthcare in a timely manner. Our attorneys aggressively represent individuals to obtain the health insurance coverage promised under the policy and the law.

Carriers most often deny health insurance claims by wrongly asserting that the treatment, procedure, or medication recommended by a patient's physician is not medically necessary under the policy, constitutes experimental treatment, or is not covered under the policy. Many times, treatment for chronic illnesses, eating disorders, organ transplants, substance abuse, mental illness, and emergency medical services are highly scrutinized and fiercely disputed by insurance carriers. Similarly, insurance carriers frequently target and impermissibly deny coverage for partial hospitalization and residential treatment for certain types of conditions such as eating disorders and substance abuse. DI Law Group has extensive experience in representing claimants in health insurance matters involving physical or mental / substance abuse issues and is determined to hold insurance companies accountable for the coverage paid for under the policy.

The Claim Denial Appeals Process

If a treatment, procedure, or medication has been denied, you have the right to challenge or appeal the denial under your health insurance policy. However, appeal rights vastly differ between policies. The attorneys at DI Law Group vigorously advocate during the internal claim appeals process and zealously litigate on behalf of our clients if insurance carriers refuse to overturn wrongfully denied health insurance coverage.

Many states provide an external appeals process when healthcare coverage is denied as not medically necessary. However, not all external appeal processes are the same and claimants should be aware of their rights and obligations before voluntarily entering into such a process. In many states, the state insurance department retains medical review companies that commonly work for insurance companies and patients do not have the ability to choose an independent evaluator. The attorneys at DI Law Group work closely with their clients to understand their rights and obligations under their policies and the law.

Which Law Applies?

DI Law Group handles both private and group insurance claims. While such policies have similarities, the difference between Group and Private Health Insurance policies can be significant - mainly in the laws that govern each. It is essential that claimants understand both their rights and obligations under their policy and the law.

Most group policies are governed by the Employee Retirement Income Security Act of 1974, ("ERISA"). ERISA places extremely strict deadlines, guidelines, and obligations on individuals. Moreover, ERISA prevents individuals from obtaining punitive damages for an insurance company's bad faith claims handling practices.

Understanding whether your policy falls under ERISA can be vital to your claim. If your claim is governed by ERISA, it is fundamental that you understand your responsibilities and rights under the law. Moreover, if your claim does not fall under ERISA, in certain states, your insurance company may be liable for its bad faith actions. However, you may be required to take certain actions before filing suit to secure your right to pursue punitive damages. At DI Law Group, we are dedicated to protecting our clients' rights under their policies and the applicable law.

Let our attorneys deal with the insurance company for you. The team at DI Law Group helps policyholders during all stages of the claims process. Let our law firm assist you by:

  • Preparing and handling your appeal of a denial of insurance benefits
  • Filing a lawsuit

To schedule a free face-to-face or telephone consultation with an experienced health insurance lawyer, contact our offices today. DI Law Group serves clients nationwide.