Health and HMO Insurance Claims

J.P. Gonzalez-Sirgo
Founder of J.P. Gonzalez-Sirgo, P.A.

According to Florida health insurance claims statistics, approximately 10% of all Florida health insurance claims are wrongfully denied coverage, but less than 1% of all policyholders denied coverage ever question their health insurer on the denial of their claim.  

When you purchased your health insurance policy on your own or through your employer, you expected your health and medical bills to be paid.  What you did not expect is to have your valid health insurance claim denied and for you to be financially responsible for health and medical bills that can instantly bankrupt you.  According to bankruptcy statistics, the number one reason why individuals file for bankruptcy protection in the United States is the crushing effect of unpaid medical and hospital debt.

Common Health Insurance and HMO Claims Denial Reasons

  • Pre-Existing Conditions
  • Experimental Treatment
  • Treatment is Excluded
  • Medically Unnecessary
  • Surgery or Transplant is Not Covered

Health Maintenance Organizations (HMO's)
An HMO is a managed care organization that provides a form of health care coverage through hospitals, doctors and other health care providers which have contracted with the HMO to provide services to the HMO's customers.  These health care providers must treat the HMO's customers in accordance with the HMO's contract terms and accept payment for these services on a pre-agreed and fixed schedule.

HMO's have Been the Target of Lawsuits for Many Reasons

  • HMO's Restrictions Prevented Necessary and Due Care
  • Negligent Selection of Physicians Admitted Into the HMO Plan
  • Refusal to Authorize Medically Necessary Services
  • Refusal to Pay for Necessary Procedures after Services Were Provided
  • Setting Payment to Health Care Providers so Low that it is Cost Prohibitive to Perform Procedure or Treatment

Document, Document, and Document
Do not allow insurance companies to force you and your family into bankruptcy or even worse, deprive you of your right to receive the necessary medical treatment required. 

If your Health insurance company or HMO claim has been denied, we recommend you take the following action:                                                                     

  • 1. Learn Your Rights Under your Policy/Contract
  • 2. Contact the Insurer for the Specifics of the Denial
  • 3. File a Written Appeal if Required by your Policy/Contract
  • 4. Demand An Independent Review

Remember to document everything and retain copies of all records.


Call Us
As a former claims adjuster, I understand why these situations come about. Insurance companies are in the business of making money.  By delaying claims, insurance companies get to hold on to their money a little longer.  Money that is invested somewhere earning them money.  As far as HMOs and Health insurance companies go, the only thing better than delaying a claim is denying a claim.

In simple terms, when you bought your health insurance or HMO policy your insurance company entered into a contract in which they promised to pay out the insurance benefits in the event you needed health services in consideration for payment of certain premiums.  You and your family were responsible and sacrificed to make those timely insurance premiums.   Don't let your health insurance company get away with taking your money but refusing to follow through with their half of the deal.

You can reach Miami Insurance Claims Lawyer J.P. Gonzalez-Sirgo by dialing his direct number at (786) 272-5841, calling the main office at (305) 461-1095, or Toll Free at 1 (866) 71-CLAIM or email Attorney Gonzalez-Sirgo directly at[email protected].

Be the first to comment!
Post a Comment