When to Hire Lawyer to Claim Against Health Insurance Denial

People pay premiums to health insurance companies. In return, the insurance firms pay medical bills when an insured person falls ill. People have good faith in the insurance companies as they lend helping hand to the needy people. Sometimes, insured people do not get the payment and coverage of medical treatment. If you are also confronting the health insurance denial problem, get the services of an attorney to claim the payment.

Written Explanation

It is the legal responsibility of insurance company to give the written explanation of the insurance denial. The explanation also includes the procedure of appealing to restore the coverage. You have limited time to file an appeal. Provide complete documents to a lawyer so he may represent your case confidently.


Know the Reasons of Health Insurance Denial

It is necessary to take into deliberation the reasons for health insurance denial. Accurate knowledge helps you to take healthy measures and prevent denials. The insured person may visit the website of the insurance company or contact the call customer service. You must understand the legal terms and ways to deal with the case. It may happen that the lawyer is not available due to genuine reasons. You should be capable enough of handling things easily. Equip yourself with health insurance denial information to make a strong case.

Absence of Referral on File

The insured patient should get a referral from their family doctor. It is prerequisite of some insurance companies. The absence of referral on file may cause the rejection of health insurance.

File a Claim Quickly

The patient should file a claim of coverage quickly. Sometimes, people do not know the period of filing application, so they get late. Consequently, they have to bear a loss. No one can turn the bad destiny if you do not file the case within the deadline.

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Use Valid HCPCS and CPT Codes

The patient has to use some CPT and HCPCS codes to complete the procedure of health insurance. The system of coding is entitled the Healthcare Common Procedure Coding System (HCPCS). The coding system should stay up-to-date. Any mistake of inserting codes or date result in insurance denial.

Bill Liability Carrier

Some insurance companies would not pay for medical treatment if you injured in an accident until you get the payment from auto insurance.

More than One Insurance Plans

Have you taken more than one insurance plans? Yes! It may cause the rejection of the medical treatment payment. Categorize the insurance companies as primary, secondary, or tertiary to avoid such panic condition.

Non-Covered Services

Some health insurance plans do not cover certain diseases. That is why; companies do not pay for its treatment.

Medical Emergency and Prior Authorization

It is imperative to get authorization from the insurance company before getting the treatment. Many insurance companies include MRI, CT scan, and Ultrasound as non-emergency cases. The patient should obtain prior-authorization to exploit insurance benefits.

Incorrect Information

Incorrect information becomes the leading cause of health insurance denial. An insured person even cannot claim if he/she provides wrong information to hide certain facts.

Take into consideration the following aspects while filling the form:

  • Write correct spelling of your name
  • Write the correct date of birth

Use In-network Providers

People may not get the benefits of health insurance if they utilize out-of-network services. The claim automatically denied when they go against the clauses of the insurance agreement. The insurance company may not facilitate the insured person if he/she is living in a foreign country and fells ill.

Difference between Rejected Claim and Denied Claim

Health Insurance Company rejects the claim when billing specialist does not provide accurate information. Ultimately, the company does not receive the documents. The insured person may get the medical payment after correcting the errors. There is an option of the resubmission to bill the services.

Denied claims mean that insured person cannot receive the medical coverage. The firm raises some serious objections. There could be any reason for the claim denial such as wrong or missing information about billing. Insurance firms explain the core cause for insurance denial.

Hire a Lawyer for Appealing Insurance Claim Denial

It is a tiresome and time-consuming process to apply for the denied insurance. The procedure is patchy, steep, and full of complexities. A common person does not know how to deal with legal matters. Do not do experiments because you have already paid the payment. Hire an attorney how has knowledge and experience to tackle the relevant matters amicably.

Understand the Insurance Policy

A lawyer takes into consideration the type of insurance policy before proceeding to the legal forum. He/she draws the line of difference between what the insurance plan covers and what it does not. The legal experts check whether the provider is in-network or not. He/she will also analyze either health insurance plan is yearly deductible.

A lawyer could flag the illegal insurance denial when he/she knows the ins and outs of the plan.

Art of Preparing Appeal

It becomes a difficult task for the patient to prepare appeal form when his neck is already in the deep water. That is why; he cannot take any action against the insurance firm. Lawyer checks the deadline and dispatching date of the denial letter. He/she takes the necessary action for your objectives. Sometimes, the insurance firm gives a little share of the insurance.

Mature Advice of Lawyer

A lawyer is an expert and experienced person who sets you in the right direction. He does not use the emotions but takes into account the facts to handle the dispute. The lawyer asks proof and proper documentation if the company does not pay money for medical treatment.

The lawyer would like to contact the provider and request him to confirm the diagnostic code. It becomes easy to fix the issue if there was a coding mistake. The provider will pursue the case and asks the company to accept your request.

Analyze the Terms of the Health Insurance Plan

It is also good to move to scrutinize the provisions of the insurance plan. If your plan falls within the orbit of the standard of care, the company is bound to deliver payment. Do not forget to consult medical magazines such as The New England Journal of Medicine and The Journal of the American Medical Association. You may know either disease is within the accepted method of care or not. You may also take help from the doctor to know the real phenomenon.

Provide the Information to Reconsider the Appeal

It becomes difficult to get the application approved if you do not know the ground reality of the insurance denial. Get the help of a lawyer who understands the matter deeply. Lawyer writes a letter to the insurance firm to reassess the whole process. All responsibilities fall on the shoulders of a lawyer whom you hire to defense your objectives.

There are numerous categorize of the lawyers. They are specialists in different domains. Hire a lawyer who has deep knowledge about insurance firms, insurance denials, and methods to recover insurance.

Write a “Matter of Fact” in the Appeal Letter

The insurance denial letter generates frustration and emotional breakup. Do not lose heart because you have not lost all the cards. Write an appeal letter to the firm to review the denial. The letter should be simple and contain “matter of fact” instead of a lengthy explanation.

Opening Statement

The opening statement should include the purpose of writing. Get the advice of a lawyer to know how to catch the attention of the insurance company. Do not forget to share the medical condition and its history. Mention the medications that you are already taking. Insurance firms enlist recognized and valid treatment institutions. Provide the required documents if you missed them in the previous attempt. Only use the certified email to dispatch the required information within a deadline.

Internal and External Appeal

Every insured person has the legal right to pursue the case at two forums – internal and external. You may ask the company to review the case thoroughly. You may go to the third party for justice if the insurance company is canceling your appeal repeatedly. You will need the help of a lawyer to push proceedings in the court.

You may also request the insurance company to speed the procedure if you are suffering from a critical health problem. It is the ethical responsibility of the company to process as soon as possible.

Call Your Doctor’s Office

The insurance company may raise some objections that the doctor has not provided the full-fledged information. You may easily get the problem fixed and send it again to the insurance firm. You are an employee; ask your health benefits manager to contact the insurance company to tell why you need the insurance support. The manager’s call could help to reverse the decision. Do not forget to inform the doctor while filling the appeal form.

It is imperative to keep the record maintain. Write the name of the person, contact no, and date.

A good lawyer knows how to prepare the case. A poor case would give you nothing except a waste of time and money. A common person cannot replace a professional lawyer. Do not keep your money at stake with self-help. An Attorney frames a concise appeal letter and tries until you win the case.

Comments 19

  1. Critical illness NZ says:

    Over this article you will get to know in detail about Health Insurance. Things to be considering include many options listed in this link. It is very useful article and would suggest others too. I am sure many people will come to read this in future.

  2. kinda desperate says:

    My wife of 43 years (she is 61) is dying from a form of pulmonary fibrosis. her pulmonologist and rheumatologist have agreed on a drug they think may halt the disease. Cigna is denying the medication.
    My wife is on oxygen, in a wheelchair, needs fulltime assistance. I work a 50 to 60 hours a week just to cover these expenses. This means of course I make too much for assistance from the drug manufacturer. Then there is the house work, helping with hygiene and doctor appointments.
    I don’t have time or energy to expend putting together an appeal and my wife is not able to so for herself.
    Cigna pays none of the costs for the above . It is a high deductible plan. I also do not use Cigna for her current prescriptions because they negotiate higher prices with the pharmacies. Prescriptions are so much cheaper without using my insurance it is not worth having those costs applied to my deductible. The same for the oxygen. It was much much cheaper to by a rebuilt concentrator than to rent one from a “Cigna approved vendor” the purchase cost what 2 months rent would be. But of course it does not get applied to the deductible. Cigna gets $28,000 a year for this and pays basically nothing if we do dot exceed the max out of pocket for the year. We typically don’t.
    I do not think Cigna is worse than any of their competitors. Basically, for profit healthcare is a grossly immoral concept.
    I include providers, insurers and drug companies in that statement. Pay or die is considered criminal under any other
    circumstance. But if you call it healthcare it is ok.

  3. Jeri meehan says:

    Is there are law firm that would like to initiate a class action against Florida Blue for causing patient detriment due to only allowing one pharmacy that is consistently out of stock of certain meds?

  4. Jeri meehan says:

    on another note: medication shortages at certain pharmacies are causing problems with patient care. For instance, Florida blue will only allow a patient to get their regular meds at walgreens (also owned by BC parent company). If there is a long term shortage at Walgreens, what are the legal ramifications if the patient goes without needed medication or is forced to pay out of pocket elsewhere? Aren’t there laws to require the insurer to allow alternate pharmacies?

  5. Shirlene Josey says:

    On May 3rd, 2021, Dr. performed a colonoscopy on me and he sent the findings to my insurance company, Humana . His findings were cell exam of body fluid, special stained specimen slides to identify organisms and microscopic genetic analysis of tumor. On July 27th, 2022,, they sent a letter refusing to check vital tests. What can I do?

  6. Sharon Jones says:

    I have had 3 carpal tunnel surgeries on my hands and now have excruciating pain in my left arm in which I had an MRI but the result was clear. The pain continued and got worst. My primary doctor referred me to a specialist who requested a MRI 3 different times, in which my former insurance denied. Since the denials and request to pay for it myself the pain is now in both arms, hands, shoulders and traveling down both legs (this is over a period of 7 months). I have taken all the steroid shots a person can take within a year and I’m at my limit of a different type of prescribed medication to minimize the pain. My employment changed insurance companies (GOOD) and I was quickly approved to have an MRI and discovered that I have a torn tendon in my left shoulder and two small torn tendons in my right shoulder. I’m in pain all day, everyday and now have started having two trigger fingers (popping) on my right hand after already having two surgeries. I will be seeking to speak to an attorney to evaluate my complaint because I have suffered greatly and continues to do so at the expense of an Insurance company I have paid into for 2 years and was so easily denied twice after paying them for two years and through my employer. I do not appreciate the delay and the constant pain at the hand of an insurance company that cares more about a damn Xray and physical therapy that I already had including everything that was ordered to do. I greatly feel that because of them, it has caused my body further strain and damage by denying me to have an MRI at the first of request months ago in order to determine the problem when the MRI was requested. The problem could have been determined and treated before traveling all down over my body and becoming worst. I am so uncomfortable and it has handicapped my social and personal life extremely.

  7. Rhonda Hyde says:

    What type of lawyer would handle these claims where insurance has denied. My uncle has been through hell. Surgery was scheduled for his back 5/12, then the insurance co came back at the last minute denying the claim. Needing a lawyer to review the case to see if we can pursue the insurance?

  8. Jacqueline Mercado says:

    I have been fighting for months trying to get 24 hour home health services for my mother who is 87 years old with dimentea and she is bed ridden due to a fall that broke her hip . Her Managed Longterm insurance keeps denying the request. What type of lawyer can help me fight the appeal?

  9. Angelo. Rebello says:

    Hi my name is Angelo. Rebello started with Ontario power generation 1978 to 2014 my provider was great west life, in 1985 was
    under to care of DR Ira. Kleinberg, in 2015 Sun life was my provider, in 2020 Mr. Derrick. King started asking me about all the treatments I had with the Doctor and that if I had all the receipts for all the treatments this 5 years later. I mailed him photo copies of all the extended benefits claim forms from 2015 to 2019, but he wasn’t happy ,he wanted master card receipts
    I mailed him all the master card receipts he is asking me to pay back for all the treatments from 2015 to 2019
    How could help
    He wants me to pay back the amount by 23 March 2021

  10. Christine M Zufelt says:

    My husband worked for IBM and resigned on the 17th of Dec. 2020. I called Net Benefits on the 18th of Dec to see if we were still covered until the end of Dec as that is what he was told. I called AETNA our insurance carrier and they stayed with me on the phone while they transferred me to Net Benefits. The person I spoke with stated I had insurance with IBM until the end of Dec. I have cancer and went in for treatment on the 21,22,28 of Dec. because I was told I still had insurance. In Jan I received the statement from AETNA that I was denied treatment on those 3 days due to the fact I had no coverage. Is there anything I can do ? I am at a loss and have stopped treatment until my Medicare kicks in next month. I would appreciate any help with this situation.

  11. Anita Marlow says:

    Received treatment for breast cancer in Mexico, and the claim was paid in pesos. When the carrier was made aware of the mistake, explaining the amount due should be American currency, the carrier then decided to deny the claim. Seeking any legal steps that can be taken to stop this unfair practice, and at least get some fair payment.

  12. karthik says:

    WHat kind of lawyer do you hire to help with denied insurance claim? and I my zipcode is 33065.

  13. Linda farrell says:

    What kind of lawyer do you hire to help with a denied insurance claim ??

  14. Renee Borek says:

    Not sure who exactly but at the very least see a pain management specialist. A regular doctor will not be able to help you – trust me on that. This type of doctor is an anesthesiologist and will help you find the right path. There are a lot of good things out there now that are not drug related – sometime that too is a necessary thing just so you can have a somewhat quality life. I I am a pain patient so I understand your frustration with pain and insurance also issues. I have heard cold laser therapy is a promising treatment. But find the specialist. There are implantable devices too that can be very helpful (nerve stimulators). I hope this helps you.

    • Wendy says:

      I see a Pain Management Specialist & have had denial after denial. It’s the company. They always deny. I don’t know what to do anymore. They wouldn’t pay for an MRI so I paid for it and half my spinal fluid was not getting through. Guess spinal fluid is not medically necessary.

  15. Todd says:

    I was having pain in my shoulder that was interfering with my math class. The doctor previously told me I had a trapezius injury and that it would go away in a year. That was three years ago? The pain got so bad, I went to an orthopedist who ordered MRI. My insurance said it wasn’t medically necessary and that they wouldn’t cover it. I took out a loan to pay for two MRIs they found stuff. Issues with shoulder, Issues with neck. I got the surgery. Almost a year later the insurance came around, a little. On the surgery, not the MRIs. I had follow up physical therapy and time was up. I needed more. Still having some issues. (partially detached bicep) Surgeon referred me to physiatrist. Physitrist said he wouldn’t help me. I began to explain nearly two decades of no one helping me because my insurance pay for anything. He ordered water therapy. It was wonderful till my wife got the bill. The insurance said not enough information. I was told to stop. I have stories dating back nearly twenty years of crap healthcare due to non payment from insurance companies. I live with a knife stick in the right side of my back. It limits me. I have right hip pain and right foot pain and right neck pain and I got sharp pain in right ear that caused ringing in ears. The doc who I saw for the ears told me to reduce my caffeine intake. Seriously?

    I cannot get care, just brush offs from poker faced docs. Covid has shut down my massage guy. So my pain is worse.

    Know anybody that can help me in Oregon?

  16. Kathryn M Smith says:

    My insurance company for 2 years now send me EOB on hormone treatments stating they need more info? The drs office has sent everything they have asked for and still nothing from the insurance company. The treatmemt is expensive and I pay out of pocket for it. I call them all the time and get no where. They are out of network but they still should deny it or pay a small potion of the office visit but they simply will not respond. Since the first of the year they have not even responded with EOBs.
    Any suggestions?

  17. Rachel Frampton says:

    My mother has been diagnosed with cancer, and when we went to the health insurance company, her claims were quickly brushed off. That’s why we have decided to start looking for a health care attorney who can help us win her claims. We’ll make sure to find a lawyer who is experienced and has tackled cases like this.

  18. Kay Trenschel says:

    What type of lawyer handles a denied medical claim?

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