Denied Medical Care

Employees may often find that their claims for medical care are denied by their employer’s insurance company, typically to save money. Sometimes claims are denied even if the employee’s doctor says the care is necessary. At this point, employees may assume there’s nothing else they can do, and may try to pay for the care themselves, or even go without treatment, which can cause serious health problems. Having your claim denied can be devastating, but you don’t have to accept the insurance company’s denial. If you’ve suffered from denial of medical care, you may have a legal claim against the insurance company.

Insurance policies are contracts between the insurance companies and the policy holders. The insurance company accepts premium payments, and agrees to provide the coverage outlined in the policy, consider the policy holder’s interests equally with the insurance company’s interests, and act fairly and in good faith toward policy holders. An insurance company is acting in bad faith when it:

• Denies payment for valid claims
• Delays payments without good reason
• Underpays claims without good reason
• Does not thoroughly investigate claims

It’s often hard to know what your rights are, since medical insurance documents are complex. Claims may require significant amounts of paperwork, and you may face endless levels of service representatives, which makes filing claims difficult and time-consuming. In addition, the laws surrounding insurance are constantly changing, and the latest health plan provisions, COBRA rules, or HIPAA information could be important to your claim.

Because health insurance companies are businesses, they increase their profit margins by minimizing the amount they pay out in benefits to policyholders. Sometimes this means the insurance company unreasonably denies a valid medical claim. Ways that insurance companies fail to provide their policy holders with the coverage they have paid for include:

Denying out-of-network medical care if the policy holder was unable to contact the insurance company for preapproval

• Refusing to cover a bill after the insurance company preapproved a medical procedure
• Denying expert care, such as an advanced medical treatment known to have successful results
• Denying unconventional care, such as treatment the insurance company considers “experimental”
• Some denials of coverage can be quickly and easily resolved, but others are much more difficult. If you’ve been denied coverage, there are some steps you can take:
• Ask what led to the denial of coverage and determine your insurance carrier’s procedure for appeals.
• When you call your insurance provider, take detailed notes and write down the names of everyone you speak to, the dates, and the times.
• Obtain the following information: a copy of the denial letter, a copy of your plan’s full benefits language, and a copy of the guidelines that the insurance company uses to determine what treatments are medically necessary.
• Ask your doctor to write a detailed letter explaining why your treatment is medically necessary, and scientifically proven. Make sure he or she provides you with a copy.

Finally, if you are unable to resolve the issue yourself, contact an attorney. You may only have a limited time from the date you had a procedure to start an appeal, so don’t delay.

If your medical insurance claim was denied, the attorneys at Friedman Rodman Frank & Estrada, P.A. will review your case to see if you’ve been unreasonably denied. If so, our Miami workers' compensation claim attorneys will consult with medical specialists and your physicians to demonstrate why your medical treatment was necessary. We will pursue all options to resolve your claim, including contacting the state of Florida’s Office of Insurance Regulation, and, if necessary, file suit. Contact our Miami/South Florida offices at 305-448-8585 or toll free at 877-448-8585, or fill out our online contact form, if you’ve been denied treatment by an insurance company. We’ll schedule a free consultation in English, Spanish, or Creole, and work to get you the medical care you need.