What to Do After Health Insurance Denial
Did you recently have a medical procedure but your insurer has refused to pay for it? If that is what you are going through, you are likely confused and upset. Don’t panic. You are neither the first nor the last individual to have their treatment claim rejection. According to an article published on AARP Magazine (November/December 2009 issue), approximately half of denials that are independently denied can be appealed successfully.
Provided you are organized, calm, and hire an experienced Insurance Denial Attorney, you should be in a position to resolve the situation. Continue reading this article to know why your health claim was not granted and steps you can take to reverse this decision.
Reasons Why a Claim Can be Denied
First, figure out what caused the denial of your health insurance claim. Prepare a list of questions about your denial and collect documents such as your policy, denial letter, a summary of benefits and insurance, immediately after getting your Statement of Benefits. Then, call your insurance provider. You can get the contact information on the back of the denial letter or insurance card.
Sometimes the claim could have been denied because of a data-entry mistake such as a misspelled name or insurance identification number. Make sure you read through all the paperwork from the insurer and search for mistakes. If you find one, contact the insurance provider before proceeding.
If your claim was not approved because of inaccurate or incorrect information submitted by your physician, call the hospital or your doctor to rectify the issue and then resubmit your claim.
Other common reasons for health claims denial include:

• It is possible that the procedure or services you received are not covered by your insurance plan even though they look like they should be
• Procedures such as MRIs, CT scans require a referral or pre-authorization from your doctor
• Denial of procedures that are well-thought-out not medically essential, experimental, investigational, or cosmetic
• If your health insurance company is an exclusive provider organization, your claim could be denied for consulting a physician outside the policy’s provider network. Using an exclusive provider organization means you are using a physician who is in agreement with your insurer in terms of payment
• The bill went to the wrong insurance provider
• Denial for typographical mistakes
• Denial as a result of policy restrictions
• Denial for timeliness

When speaking with the insurance representative, make sure you take notes. Take note of the representative’s name and date and time of the conversation. These details will assist you in building your claim and helps the next representative you talk to access your file with ease.
That could be the end of the denial. Sometimes health claims are not granted because of an error that can be rectified using one call. However, if this is not possible, you may need to appeal the insurance company’s decision.
Appealing a Health Claim Denial
If your insurance company refuses to pay your claim, you can appeal or respond. Usually, a formal appeal entails sending the insurance provider a letter asking them to reexamine their decision.
Be precise in your letter about the reason the insurer should pay the claim and the reasons for the denial mentioned in the notice of denial. You can also include information on why you require the medication or procedure as well as evidence such as lab results, medical records, and X-rays. This will help the claim process faster. The explanation of benefits (EOB) you received should be able to guide you on how to appeal your insurance company’s decision. If you are not sure, call the insurer directly.
If the claim was denied as a result of the lack of previous authorization or inadequate medical necessity, you could request your physician to write a letter of medical need. The letter should give details about your recommended treatment options, diagnosis, and treatment duration.
It is worth noting that you should file the appeal within one hundred and eighty days of receiving a denial notice.
Bad Faith Insurance Denial and Lawsuit
According to the law, your insurer owes you a duty to act in good faith when you file a health insurance claim with them. In other words, the insurer should not search for ways to deny you the benefits. Doing so constitutes bad faith. The insurer’s bad faith health coverage denial could be as a result of:

• Fabrication of proof
• Refusing to accept evidence
• Refusing to conduct investigations
• Irrational delay in conducting an investigation
• Unreasonable compliance with bureaucratic requirements or minor procedures, and
• Other reasons that show the insurance company acted unfairly.

Some courts allow tort claims. Torts are different from insurance contracts, in that you can receive punitive damages.
Filing a Bad Faith Health Insurance Lawsuit
Although the elements of a bad faith lawsuit vary from one state to another, you should prove:

• The reason for withholding your benefits was unreasonable
• Damages that were payable to your insurance plan were withdrawn

It is smart for every plaintiff to be watchful of the statute of limitations for bringing a bad faith health insurance lawsuit. Although you might not want to go to court before giving other avenues like appealing the health insurance denial or negotiations a try, there is a time limit for filing your claim that varies from state to state. This is one of the areas where a competent Insurance Denial Attorney comes in handy.
Recovering a Bad Faith Insurance Claim Successfully
Recovering a bad faith health coverage lawsuit depends on your state laws. However, if you succeed in your claim, you could recover both compensatory damages and contract damages. Compensatory damages are compensation for pain and suffering, lost wages, and medical expenses. Contract damages, on the other hand, is the money that was payable under the insurance policy. Sometimes, if the insurer’s actions were appalling, you could be awarded punitive damages.
It can be frustrating to pay your insurance premiums on time and in full only to have your insurer deny a claim when you require it the most. Fortunately, you do not have to go through this experience alone. If you’ve any concerns about health coverage laws or require assistance with bad faith health insurance lawsuit, it is wise to contact an experienced Insurance Denial Attorney near you.