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 purchase health insurance, you expect your  medical bills to be paid.  What you do 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

If your Health insurance or HMO claim has been denied:                                                                   

  • 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.

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].

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