Friday, April 19, 2024

Can You Sue Insurance Company For Denying Surgery

How To Select A Health Insurance Lawyer

Tricks Insurance Companies Use to Deny Your Claim

Dealing with insurance companies can be frustrating and time-consuming. You want to hire an attorney who focuses on health insurance cases and who understands insurers systems. A lawyer who has worked on the other side representing insurance companies knows them best. And an attorney who has litigated the same types of cases can offer your highest chance of success.

Things To Consider Before Making An Appeal

While you may believe you have a good chance of winning an appeal and having the insurance company reverse their denial of your claim, there are factors to consider before choosing this option.

  • an appeal could take months, even years and during this time you cannot work and earn an income and may have very limited financial resources to live on
  • you may miss the deadline to file a lawsuit, which insurance companies say begins from the time they send their first denial letter to you
  • you may provide further medical evidence that harms your appeal

When Can Treatment Be Denied

Refusal of medical treatment might occur in emergency rooms and urgent care clinics. Typically, soon after you arrive, a triage nurse talks to you about your symptoms, then checks your breathing, pulse, blood pressure and temperature.

The triage nurse must determine how urgent your injury or illness is compared to other patients waiting to be seen. People with life-threatening conditions will be seen before patients with other types of injuries or illnesses.

For example, a patient with head trauma, serious burns, or other critical injuries will be treated right away. Someone with a sprained ankle may have to wait for several hours before being seen.

If you get tired of waiting and leave the hospital, youll have a hard time convincing a judge that the hospital denied your emergency care.

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Why Do Auto Insurance Companies Deny Claims

Your car insurance company may offer a range of reasons for denying your claim. Some of the most common ones are listed below:

  • Lack of relevant insurance coverage
  • Application and claim errors
  • Auto insurance fraud
  • Bad faith denial

Claim errors are very common and important to keep in mind. One common example is not notifying your insurer in time, which in some cases is as short as 24 hours.

Insurance companies wont explicitly give bad faith denial, but they often use legal language and fine print to deny your claim. Since providers lose money when they pay out claims, they often attempt to deny as many car insurance claims as possible. Those who prove that their insurer gave a bad faith denial may be able to sue for punitive damages under the tort system.

If youve got a strong argument for your claim, then you can sue your auto insurance company. Make sure to hire a reputable law firm, even if it has higher attorneys fees, and prepare for what could end up being a drawn-out process to receive a fair settlement.

Denials / Appeals: What To Do When Your Insurance Company Denies You Coverage

Can You Sue Your Own Insurance Company?

Before my son was diagnosed with T1D, I had never been denied for a treatment. I was shocked and felt really upset when I got the notice. I talked with another mom who has a child with T1D, and she encouraged me to file an appeal. Id never even heard of that! The first time, it took me several calls to the insurer and my sons doctor, but when I finally got the appeal submitted, it was accepted! Now if I see a denial come through, I know what I need to do, and its not as scary.T1D caregiver, TN

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Can I Sue My Insurance Company If They Deny My Claim

Yes, you can sue your insurance company, especially if you believe that the insurance company has acted in bad faith. You can sometimes solve these problems, however, with the help of a lawyer before launching a lawsuit. Remember that insurance companies are for-profit businesses. They hate losing money. If they see that you are not going to be put off by their denials and that you consider suing them for their actions, it may be cheaper for them to settle with you. They can then avoid paying all the expenses that are involved in a lawsuit such as attorney fees, court costs and perhaps a higher settlement than anticipated.

Some companies, however, will continue to deny your valid claim. Insurance companies are required by law to abide by the terms of your policy and act in good faith. They also cannot engage in unfair trade practices. If you think that the insurance company is engaged in any of the following activities, you should contact an attorney immediately:

If you believe that your valid claim was denied for any of the above reasons, you probably have grounds for suing the insurance company. You should immediately contact an attorney familiar with the tactics used by insurance companies to undermine valid insurance claims.

Who Are The Lawyers That Sue Insurance Companies

When suing an insurance provider for denying a claim, its best to work with a specialized attorney. An insurance claim lawyer is someone who specializes in this type of case.

The insurance industry is a heavily regulated market. You can benefit from working with a specialist who knows about these regulations. Plus, insurance claim attorneys have advanced negotiation skills and can sometimes come to an agreement with your insurer before going to court.

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How To Sue The Insurance Company For A Denied Claim

To initiate a lawsuit against their insurance company for wrongfully denied claims, the insured or a bad faith insurance attorney on their behalf will file a complaint with the appropriate local court. The court will hold a hearing, during which both sides argue their cases and present evidence before the judge who ultimately issues a ruling.

In making a determination, the court will consider factors such as whether the contract requires the insurer to pay, that the policy covers the type of claim filed, and that the insurance company did not act in good faith in its handling of the claim. Often, legal representatives in such cases will establish patterns of mishandling clients cases by the insurance company making it easier to prove bad faith.

Can I Be Denied Surgery Because Of Nicotine Use

Insurance companies facing lawsuits after denied Business Interruption claims
  • Posted on Jan 8, 2014

Yep, I think so. You have no constitutional right to medical treatment nor can the doctor be forced to operate on you. He wants you to quit smoking so that you have a better chance of healing up well from the surgery. Asking you to quit without giving you any help is a bit harsh, though. I see this “stop smoking before we operate” request frequently in back surgery cases. Keep in mind that if you don’t quit as directed by the doctor, you may be deemed to be “noncompliant with medical care” which may affect all of your workers’ comp benefits. You can ask the doctor to either prescribe something to help you quit or send you to a doctor who can help you quit.

This answer is intended as general information and not as specific legal advice. If you want to have a free consultation with me, please contact me through AVVO.

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Who Should You Sue

There are usually three parties that you may be able to sue when your claim for LTD benefits has been denied or your benefits have been terminated:

  • the insurance company,
  • the insurance broker who sold you the LTD insurance policy, or

A disability insurance or personal injury lawyer can help you to decide whom you should sue. In most cases, lawsuits are brought against the insurance company who denied the claim.

Do Health Insurers Cover Si Joint Fusion

The standard of care for SI joint dysfunction is SI joint fusion. The premier spine surgeon associations in the United States consider the procedure medically necessary and not investigational. Many of the major health plans cover this surgery. But some health insurance plans do not cover SI joint fusion because they claim it is investigational. Why are there discrepancies in coverage from different health plans? Because each health insurer sets its own policy with internal clinical guidelines for when treatment is considered medically necessary. So Anthem Blue Cross, Blue Shield, Aetna, Cigna, Kaiser, Health Net, UnitedHealthcare, Oscar, Magellan, Molina, and others have different plans. Policies are often created internally and evaluated by external doctors who choose whether the specific policy is correct. But the process may include incentives to deem a policy correct when in fact it is overly restricting. For example, often the external doctors are paid by the insurer. These doctors may want to eventually work for the health insurer. And corporations like insurance companies have incentives not to include expensive treatments because the cost impacts their bottom line.

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How Can I Appeal The Denial Of My Claim

Most insurance companies allow policyholders to appeal a denied claim. If you were in an automobile accident, an attorney can help you gather the information that you may need to submit to address the denial. If you are appealing a denied medical claim, an attorney can also help you gather the important documentation. Documentation includes medical records, invoices for treatment, a police report or hospital admittance record in the event of an accident and even personal statements from friends and family about how your medical situation is affecting your life.

There are things that you can do, however, that will increase the likelihood of making a successful appeal:

Suing For Bad Faith Conduct

Letter to Appeal a Medical Claim Denial (with Sample)

In addition to seeking compensation for a claim that should have been covered by your policy, you can also sue an insurance provider if they conduct bad faith tactics with regard to your policy and your claims. If your insurance provider engaged in bad faith, you might be able to go straight to filing a lawsuit without exhausting all of the internal and administrative appeals.

There are a variety of bad faith tactics that health insurance providers may undertake, and these tactics may either explicitly violate California law or violate the implied promise of good faith and fair dealing that is present between insurance providers and policyholders. Examples of bad faith conduct by insurers may include:

  • Deliberately misconstruing policy terms
  • Refusing to communicate with policyholders regarding a claim
  • Unjustifiably delaying an investigation
  • Failing to provide a proper explanation for denying a claim
  • Engaging in stalling tactics such as limiting communication or issuing unreasonable demands for documents and evidence
  • Delaying payments on an approved claim
  • Misleading customers about policy coverage before they purchase a policy
  • Deliberately misinterpreting the type of treatment as experimental, cosmetic, or medically unnecessary

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How To Appeal An Insurance Company Decision

If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.

You can ask that your insurance company reconsider its decision. Insurers have to tell you why theyâve denied your claim or ended your coverage. And they have to let you know how you can dispute their decisions.

Note: If you want to appeal a , see Can I appeal a Marketplace decision?

Why Are Healthcare Claims Often Denied

Your attorney will determine exactly why your insurer denied your claim, but the most common reasons for healthcare denials include:

  • Errors in paperwork, omissions, or mix-ups
  • Your healthcare provider is questioning whether your procedure, test, or prescription drug is medically necessary
  • Your healthcare provider wants you to try a less expensive option before it pays for the requested service
  • Your plan doesnt cover the service requested
  • Your healthcare provider claims you used an out-of-network provider
  • You failed to obtain pre-authorization for a procedure or test

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Texas Health Insurance Denial Attorney

For policyholders located in Texas and across the nation, it is not uncommon to have your health insurance claim denied or delayed. According to a study by Medical Billing Advocates of America, 1 in 7 health insurance claims are denied. In other words, an obscene number of claims are denied each and every year. We help health plan recipients fight wrongfully denied claims. For many clients, we handle these legal actions on a contingency basis in which we do not collect a fee unless we recover money for you.

One of the most common reasons for medical denials is lack medical necessity. This means that your health insurer does not believe you need the treatment recommended by your doctor. Medical necessity disputes tend to be more contentious because an insurance adjuster who has never treated you has concluded that your medical condition is not all that serious. Policyholders stuck in this situation are often left stressed out and worried about the financial implications of being stuck with either deteriorating health or unpayable medical bills.

If you are experiencing a denied health insurance claim, do not despair. You have the right to appeal the denial and to sue your insurance company for damages caused by the denial. A good first step is to speak with an experienced health insurance attorney to understanding your options.

Contact Stoy Law Group

Deny, Disclaim, Delay – How Health Insurance Companies Really Work

Having your insurer deny your claim can be stressful and discouraging.

However, you should know that you have options available. You can reach out to your insurer and request an appeal, file a complaint with your states regulatory agency, and file a lawsuit.

If you decide to file a lawsuit or need help with navigating the appeals process, having an experienced insurance claim lawyer by your side can make a significant difference.

At Stoy Law Group, denied insurance claims are one of our specialties. Contact us for a free initial consultation to find out if your denied claim is grounds for a lawsuit!

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Reasons Why Your Denied Claim May Be Overturned

When a claim is denied for lack of medical necessity, it is important to understand why your physician recommended the treatment. Sometimes, a denial can be overturned once an explanation has been given to the insurance company. It is not uncommon for a reviewer to simply overlook important details about your medical condition or simply misunderstand why the treatment was recommended.

Sometimes medical providers do not provide the insurance company with sufficient documentation to make a decision about the claim. When this is the case, your provider may supplement the records so the denial can be reversed. Similarly, the provider may have provided inaccurate information about you including your personal information, insurance information, or billing codes needed for the carrier to decide on the claim.

As previously discussed, a large number of claims are denied due to medical policies implemented by the health insurer. Sometimes your physician may be able to advocate on your behalf to persuade the insurer to accept coverage.

Federal Laws Regulate Emergency Treatment

Before the enactment of civil and patients rights laws, patients who couldnt pay were often refused treatment or transferred at public hospitals even when they were in no condition to be moved.

Today, hospitals with emergency departments that qualify for Medicare are mandated by state and federal laws to provide emergency care to all patients, regardless of their ability to pay.

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Private Doctors Can Refuse To Treat

A private doctor is not subject to the provisions of EMTALA and can dismiss you as a patient at any time, for just about any reason other than discrimination, without fear of liability.

Under the Civil Rights Act of 1964, you cant be refused treatment on the basis of your age, sex, race, sexual orientation, religion, or national origin.

Doctors in private practice are essentially small business owners and are not required to treat patients who cant pay for their services.

A doctor can refuse to treat a patient because:

  • The doctors practice is not accepting new patients.
  • The doctor doesnt have a working relationship with your health insurance company.
  • The doctor chooses not to treat patients with the illness or injury you suffer from.
  • You cant pay for the costs of treatment.
  • You or your spouse are a medical malpractice attorney.

Your doctor can refuse to continue treating you because:

  • You havent paid your bill.
  • The doctor has stopped doing business with your health insurance provider.
  • You continue to exhibit drug-seeking behavior.
  • You are a disruptive patient.
  • For reasons of conscience. Reasons can include religious, contraceptive, or palliative care beliefs, or deciding not to prescribe narcotics for pain management.
  • The doctor learns you or your spouse is a medical malpractice attorney.

If your health would suffer, the doctor must continue to treat you until youve had time to find a new provider.

Should I Consider Trying Out Small Claims Court

Health Insurance Appeal Letters &  The Appeals Process

It will be a much less prolonged process if you head to small claims court to address your personal injury or property damage claim. The at-fault party will be determined much quicker by taking your accident claim to this type of court because the maximum payouts are far smaller.

Small claims courts have maximum payouts that vary depending on state insurance laws. Accident lawyers can sue for up to $20,000 in damages in Texas, while the maximum payout is only $2,500 in Kentucky and Rhode Island. Maximums range across the remaining states, with California law allowing up to $10,000, Florida up to $8,000 and New York usually up to $5,000.

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