How to Proceed When an HMO Denies Coverage for Your Claim

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

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.  Some suggestions for patients who are denied coverage for treatment of their medical condition by their HMO follow:

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 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

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
  • 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
  • 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 Health 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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