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 may be resolved with nothing more than a phone call to the insurance carrier and/or the medical provider, disputes about whether a particular cancer treatment is medically necessary involves complex issues.  What do you do when your HMO or health insurance plan denies coverage for treatment:

  • Review Your Denial of Coverage Letter: The first step is to ascertain your health insurance carrier’s basis for denying your claim.  The denial letter should state what specific facts, exclusions, terms, or conditions and/or policy language is being relied upon for the denial.
  • Secure a Copy of Your Health Insurance Plan: While you should carefully read the entire plan, you will want to pay specific attention to the provisions cited by the denial letter as the basis for the insurance company’s decision.  When you are examining the plan also look for other provisions that appear to grant coverage for the treatment.  
  • File an Appeal If Required by Your Plan/Policy: Many HMO plans require you to exhaust 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/Health Insurance Company: Under Florida law, a health care subscriber/insured who successfully sues an HMO/health insurance company for denying coverage can recover attorney fees.

Litigation of coverage disputes with your HMO or health insurance provider can cover a broad range of issues including:

  • Failure to pay for necessary medical care
  • Denial of claim based on allegation that medical condition is pre-exisiting
  • Denial of claim based on allegations of material misrepresentations in the application for insurance
  • Denial of claim based on allegations that medical treatment at issue is experimental or not medically necessary
  • Denial of claim based on allegation that the subject medical treatment is not covered or is excluded under the plan or policy

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].

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