Steps to Take If Your Valid Health Insurance Claim is Denied
Most insured Americans have frustrations with their health insurance company. If we haven’t been denied care ourselves, we may have heard stories about people who are gravely ill being denied prescription drugs or necessary tests, procedures or medical treatments. Even Medicare sometimes denies legitimate claims. In the worst cases, people who were denied coverage have died as a result.
If your valid health insurance claim was denied and the lack of care caused your illness to progress or your loved one’s claim was denied and they died as a result; then you may be able to recover damages with the help of a personal injury lawyer.
What to do if your valid health insurance claim was denied
The first step to take after a valid health insurance claim is denied is to find out why your claim was denied. If you request to know why your insurer denied the claim, they are legally obligated to tell you. Contact a customer service representative at your health insurance provider to get started. Next, review your health care policy to see if your claim should have been covered.
Find out if your doctor simply needs to resubmit the claim using a different medical billing code. If the code was correct, patients may still have success re-submitting the claim along with a letter from their doctor, supporting literature for the procedure, test or treatment and a copy of the denial letter.
If the claim is denied again and you believe that it was a valid health care claim based on your health insurance policy, it may be time to file an internal appeal.
Filing an internal appeal
The first thing to do is find out how long you have to file the appeal and to get everything organized and turned in well before the deadline. Ask your health insurance company to explain the process that must be used to file an appeal. Be sure to keep paper copies of every letter or relevant medical record or bill. Request and gather any relevant documents that you don’t have. Keep a record of names, dates and details of conversations you have about the denial.
Steps to filing an internal appeal:
- Ask for a formal written response explaining the denial.
- Write a letter that formally appeals the denial. Your physicians and the consumer services division of your state insurance department or commission may be able to help with this.
- If your internal appeal is denied, request an independent external review. Note that a person who is in a life-threatening health care situation may be able to request an external review at the same time as an internal review is being conducted.
- Consider hiring a personal injury lawyer to help fight on your behalf.
What to do if internal and external appeals are denied
If you don’t have success in getting the claim approved through an internal or external appeal, go to your health care provider to explain the situation and ask if they will reduce the bill. It may also be time to consider suing your health insurance company.
Can I sue a health insurance company for a denied claim?
Health insurance companies are required by law to act in good faith when handling health insurance claims or a request for care that is covered under their clients’ policies. When legitimate health care is denied, there can be terrible consequences to patients including the progression of an illness or even the death of a loved one. When a health insurer acts in bad faith, the insured may be able to recover damages through a civil lawsuit.
If you were injured because your insurance company acted in bad faith, you have enough to deal with. Let an experienced medical malpractice attorney fight for justice on your behalf. It is not uncommon to receive a settlement from the insurance company that is five to ten times larger with the help of a medical negligence lawyer. Call the most experienced practicing medical malpractice attorneys Bellingham has at Tario & Associates, P.S. today for a FREE consultation! We have been representing people injured by medical negligence in Whatcom County, Skagit County, Island County and Snohomish County since 1979. You will pay nothing up front and no attorney fees at all unless we recover damages for you!