Health Insurance Litigation Claims

Having a medical claim denied can cause significant stress, deprive you or a loved one of needed medical care, and waste your time as you attempt to get to the bottom of the denial by your insurance company. The attorneys at Davis Levin Livingston have significant experience in litigating against insurers that fail to cover legitimate medical care.

Some claim denials result from honest mistakes — such as an omission on a written form — that are rectified with a simple phone call. Others involve complex medical and financial issues that require assistance from an experienced insurance litigation attorney.

To avoid a claim denial, consumers should understand the details of their insurance policies, including covered and noncovered services, co-payment amounts, deductibles and other details. If you receive a letter stating that your insurer has denied coverage, consider the following steps:

  • Review your insurer’s process for appealing a claim. In the summary of benefits and coverage documents, insurance companies must provide detailed information about making an appeal. In most cases, your claim will be subject to a deadline for appeal.
  • Store all paperwork relating to your claim in one place. Include bills from your medical provider along with “explanation of benefits” summaries that arrive in the mail, medical records and claim denial letters.
  • Write down all the details you can recall, including your medical condition and treatment.
  • If you receive coverage through your employer, contact your human resources department for direction on appealing the claim denial.
  • Contact an attorney experienced in insurance litigation. Your attorney may ask your medical provider to prepare a letter of medical necessity to support the validity of your insurance claim.
  • In any conversation with your insurance company, take detailed notes. Include the date and time, duration of the call, the name and title of the person who took your call, and any additional details.
  • Follow up frequently with your insurance company to check the status of your appeal.

Affordable Care Act rules

Under the Affordable Care Act, consumers can appeal any decision by a health insurer to deny a claim or to terminate coverage. The following rules are in effect for health plans created after March 23, 2010, along with plans that have been altered in specified ways since that time:

  • Consumers may request an internal appeal, which requires an insurer to fully and fairly review its decision.
  • The right to an internal appeal takes effect when a new plan year begins.
  • If the insurer still rejects the claim, a consumer may request external review, in which an independent third party either rejects or upholds the decision.
  • If an external reviewer reverses a claim denial, the insurer must provide payment for services requested in the claim.

Filing a Proper Appeal

The details required in a claim appeal can be highly complex, but presenting them properly is critical for a successful appeals process. For plans that began on or after Jan. 1, 2012, consumers who do not speak English have the right to receive information about appeals in their native language.

A right to an appeal depends on the state in which you live and the specific type of health plan you have. Some group plans include requirements for several levels of internal appeals before a consumer may request an external appeal.

An appeal may require proof that treatment qualifies for coverage under the benefits and rules of a specific plan. Analysis of specific plan language will be needed. In other appeals, the issue is whether a given treatment is necessary in the specific medical situation and whether it has been proven scientifically to work. Prevailing in such an appeal requires detailed research of medical evidence, including studies that show the effectiveness of the same treatment in similar cases.

Pursuing Claims with Experienced Attorneys

Improper denial of claims can cause real harm to consumers. For example, one recent study found that insurance denials have resulted in cancer patients with moderate to severe pain being denied medications they need, leading to both severe physical pain and emotional stress for patients and their loved ones. Many claims are wrongly denied, research has shown, and denials often are overturned upon appeal.

When appeals through your insurance company fail, Davis Levin Livingston can help. Our experienced attorneys can assist you with initiating litigation to compel an insurer to pay a rightful medical claim. Taking a case to court may require evidence from medical journals along with testimony from doctors, scientific researchers and other experts. If you believe that you or a loved one has had a medical claim improperly denied by an insurer, contact Davis Levin Livingston at (866) 806-4349.