Health Insurance Claim Denied: Patients Have Effective Options for Challenging Adverse Decisions

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

Many patients endure serious medical conditions, injuries or illnesses that necessitate a stay in the hospital.  The peace of mind provided by health insurance during a period of hospitalization can ease the stress and anxiety associated with the extraordinary cost.  Unfortunately, many patients return home to the unpleasant surprise of a bill in the tens of thousands of dollars along with a letter indicating that their insurance claim was denied.  While this can be both upsetting and stressful, patients can successfully fight a denial of their insurance claim. 

While the Affordable Care Act (i.e. “Obamacare) adopted a new formal appeals process, policyholders who challenged denials of coverage frequently prevailed prior to the recent health care law changes.  While federal law permits all Americans to sign up for health insurance plans, this does not mean that all claims will be covered.  If you receive a notice indicating that a health care procedure or service is not covered, you have the right to appeal the adverse decision.  The Affordable Care Act (ACA) implements national standards and affords policyholders the right to appeal denials to the insurance company and a third party reviewer. 

Health insurance companies often render coverage decisions adverse to policyholders based on administrative errors.  For example, a policyholder might not be properly imputed into the insurance provider’s system, so the information on the insured indicates that he or she is not yet enrolled.  Data entry errors also can occur in terms of imputing codes that result in adverse decisions because the service or procedure code entered is not covered given the circumstances. 

Another common form of error in denying claims involves improper decisions about the medical necessity of a procedure or treatment option.  The insurer might consider the treatment experimental or unnecessary given the patient’s diagnosis or symptoms.  When these decisions are made about coverage, supplemental information from your doctor can make an enormous difference.  Frequently, the denial is a product of the insurer relying on inaccurate or insufficient information about your condition. 

NPR recently reported on the case of Tony Simek who had his sleep apnea related claim denied based on the insurance company’s initial conclusion that the procedure was unnecessary.  Generally, the severity of sleep apnea can vary dramatically between patients, but Simek’s severe sleep apnea was life-threatening.  He began falling asleep while he was driving.  Simek’s physician recommended an additional sleep study to determine if Simek’s nocturnal breathing machine needed to be adjusted. 

The insurance company denied coverage based on the procedure not being medically necessary.  Despite Simek spending hours on the telephone with his health insurer, he was unable to persuade his health insurer to change its decision.  Simek eventually filed an appeal with his state’s department of insurance and prevailed.

A study conducted by Capital Public Radio found that patients who appeal denials of coverage win almost half the time in Simek’s state.  This data is consistent with studies of health insurance coverage appeals in other states.  A report by the General Accounting Office found that 39-59 percent of appeals directly to insurance companies were successful even prior to the new process standardizing appeals.  Appeals to a third party like state insurance regulators also were successful 23-54 percent of the time.  If you are not successful in pursuing an appeal, an experienced Florida health insurance coverage attorney might be able to file a lawsuit for breach of contract and/or bad faith.

If you have had your health insurance claim denied, we invite you to contact my Miami insurance claims dispute law firm.  My law firm represents policyholders in claims disputes 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.

1 Comments
To say insurance companies make bad faith decisions is far worse than " bad business" - it's criminal; and yet, bad faith claims by insurance companies seems to be epidemic in many disciplines .I can , however, only speak to my health insurance claim handled by this firm. Sadly, not enough people realize they have been severely wronged facing " big business"; nor do they realize that wonderful assistance is available. Did anyone read " The Rainmaker" -or- see the film adaptation of Grisham's novel? In that story, a young man died because the insurance company wouldn't pay for treatment. A travesty of business practice ; more tragic, its denials of all issues continue happening. Contact JP for help.
by Diane Bmmler September 8, 2015 at 03:35 PM
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