When Insurance Coverage Is a Matter of Life and Death: Appealing Denial of a Health Insurance Claim

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

Insurance carriers who wrongfully deny legitimate claims by policyholders can exact a devastating toll. However, the hardships associated with such unjustified denials are even more harmful if the claim involves health insurance.  The ordeal involved in fighting an insurance carrier to obtain coverage of medical treatments is stressful, but there are approaches to improving the chance of getting health care services covered.  There are relatively simple problems that can be resolved with a phone call, such as a coding error made by your doctor or a hospital.  By contrast, certain health coverage issues involve complex medical questions, such the appropriateness of a particular cancer treatment.

If you receive notice that coverage for your health care issue is denied, the first priority is to ascertain the basis for denial of your claim and the insurance carrier’s policies and procedures to appeal coverage decisions.  When engaging in communications with a health plan, an insured must heep meticulous records regarding the content of the communications and names of insurance company representatives.  Certain documents should be requested that will facilitate a patient’s ability to reconstruct the pathway that led to the denial.  Key documents that will be necessary to appeal the decision include: (1) the denial letter; (2) copy of the plan’s full benefits; (3) and the guidelines detailing what the insurer considers medically necessary.  There are some large health care providers like Aetna, Inc. and Cigna Corp. that post their health care plans on the Internet.

An insured’s success in obtaining coverage will often turn on the policyholder’s ability to establish that the treatment falls within the plans benefits and rules.  The policy must be reviewed to identify the language that establishes the health care sought falls within the policy coverage.  This process generally is complex and requires a nuanced reading of hard to understand and ambiguous policy language.  The best option for successfully making this argument is to retain an experienced Florida health insurance claims lawyer.  Lawyers that handle this type of insurance coverage dispute will be familiar with the types of language that insurers rely on when refusing to pay for medical care.

Many health coverage denials are tied to the issue of whether the proposed diagnostic or treatment alternative is medically necessary and/or scientifically proven.  If this is the grounds for refusal to cover your claim, our Florida bad faith claims law firm often works with physicians to obtain detailed letters supporting the medical necessity and anticipated benefits of the relevant procedure. 

Legal representation from an experienced Miami insurance lawyer can have a dramatic impact on the outcome of your claims dispute.  However, a patient on his or her own might want to research scientific evidence regarding the benefits and effectiveness of a particular treatment online at websites like pubmed.gov, which is sponsored by the National Library of Medicine.  Studies revealing positive results treating the insured’s condition in similar situations can provide effective evidence.    While the most persuasive evidence will include large random trials, other supportive articles published in reputable medical journals also can be helpful.  If you bring such research to your physician, the doctor might be able to assist you in presenting the information in a persuasive manner.  Sometimes the researchers that perform such studies also will provide assistance to patients trying to obtain urgent treatment.

If your employer has a self-funded health plan that is administered by a private insurer, a denial of your appeal by the insurer might necessitate filing a lawsuit in federal court.  If the coverage is an individual policy or employer plan, you might have the right to utilize the state’s appeals process depending on the jurisdiction and surrounding circumstances.  Although most states offer independent reviews through the state’s insurance regulatory agency, these agencies do not handle all types of issues.  A lawsuit filed by a Florida insurance claims lawyer might be able to request benefits under the policy as well as insurance bad faith damages. 

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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