How to Proceed When an HMO Denies Coverage for Medically Necessary Treatment

When health insurance companies fail to cover necessary medical treatments, patients often experience frustration and stress.  Sometimes an HMO denies coverage for something as simple as a coding error by the medical provider while other denials of coverage involve complex medical issues.  While a coding error can be resolved with nothing more than a phone call to the insurance carrier, disputes about whether a particular cancer treatment is medically necessary involves complex issues.  Florida health insurance claims attorney J.P. Gonzalez-Sirgo has provided some suggestions for patients who are denied coverage for treatment of their medical condition by their HMO.

Preparing to Challenge a Denial

Review Your Denial of Coverage Letter: The first step is to ascertain your health insurance carrier’s rational for denying your claim.  The letter should indicate what specific exclusions, terms or conditions and/or policy language is being relied on to justify denying your claim.

Secure a Copy of Your Plan’s Benefits: While you should carefully read the entire plan (often referred to as “Evidence of Benefits”), you will want to pay specific attention to the provisions cited by the denial letter to justify the insurance company’s decision.  When you are examining the policy also look for other provisions that appear to grant coverage for the treatment.  An important provision that impacts many patients who have their claim denied involves what the health insurance company considers “medically necessary” procedures.  Typically, the representative of the insurance company that determines a procedure or treatment is not medically necessary will not have even examined the patient.

File an Appeal If Required by Your Policy: Many HMO plans require you to exercise administrative remedies by filing an appeal prior to filing a lawsuit.  If your policy requires this form of pre-lawsuit procedure, you need to file a timely appeal based on the deadline provided in the policy.

Obtaining Legal Assistance to Fight Denial by an HMO

Under Florida law, a health care subscriber who successfully sues an HMO for denying appropriate treatment or for failing to fully pay a claim can recover attorney fees in a successful lawsuit brought against the HMO.  This can be a lifesaving decision if your insurance company is denying medical treatment for cancer or another potential fatal condition.  Even when the amount of the claim is relatively small, you may still be able to obtain legal assistance from an experienced health insurance claims attorney because the time involved in representing you can be covered by an attorney fee award.

Litigation of coverage disputes with your HMO can cover a broad range of issues including:

  • Failure to pay for necessary medical care after the care has been provided
  • Establishing payments to health care provides that are so low that medical providers cannot feasibly provide necessary procedures
  • Denial of medically necessary treatment or care
  • Lack of proper screening of doctors included in the plan
  • Limitations or restrictions of the plan bar medically necessary care

If your HMO is refusing to provide medical care or to fully compensate you for your claim, experienced Florida health insurance claims attorney J.P. Gonzalez-Sirgo can analyze your situation and advise you of your options.  Mr. Gonzalez-Sirgo handles disputed claims in Miami and throughout Florida.  The Law Firm of J.P. Gonzalez-Sirgo, P.A. offers free consultations and case evaluations.  No Recovery, No Lawyer Fees.  Call 305-461-1095 or Toll Free 1-866-71-CLAIM.

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