Claimants Have Options in Bad Faith Insurance Denials

When a health insurance company denies goes too far and denies a valid healthcare service in bad faith, it can be very detrimental to the policy holder.

Fortunately, there are a lot that claimants can do to resolve an incorrect denial of health care services, such as autism treatment.

Many strategies that might help resolve the claim administratively can also strengthen the claimant’s position for filing a bad faith lawsuit over autism treatment denial or other needed service.

Sometimes simply clearing up the facts of what happened can resolve an improperly denied healthcare service. Denials that at first appear to be made in bad faith may just be clerical errors, like an incorrect code entered on a form. These can sometimes be cleared up with no more than a phone call.

Bad Faith Insurance Practices

Other denials may rise to the level of what’s known as “bad faith.” Generally, an insurer is acting in bad faith when it refuses to uphold its end of the bargain.

Some state laws list specific acts by insurers that constitute bad faith. In California, for example, bad faith includes not just the unreasonable denial of claims but also failing to act promptly on a claim, failing to provide prompt justification for the denial of a claim, or advising a claimant not to hire a bad faith insurance lawyer.

A claimant who suspects bad faith on the part of her insurer can start with a thorough investigation. The claimant will want to get and review a copy of the full language that governs the benefits plan, which insurance companies sometimes call “Evidence of Coverage.”

The claimant will also want to have a copy of the letter giving notice of the denial, which may state the reason for denial up-front.

The insurance company may also publish specific language that says what procedures it does or doesn’t consider medically necessary when it comes to services such as autism treatment.

Claimants and insurance companies don’t always agree on whether a particular procedure is qualified for coverage, and it’s important to review the policy’s language thoroughly to build a case in favor of coverage.

Sometimes insurers reject coverage on the grounds that the claimed treatment is not scientifically proven or medically necessary. Arguments like this can involve a lot of technical medical information.

Claimants might do best by simply asking for help from their doctor in the form of a letter explaining the need for the treatment. It’s also possible to get another doctor to review the claimant’s medical records and write up an opinion supporting the need for treatment.

If the insurance company still denies the claim, it may be time to appeal to a third party. There may be an appeals process available through a state government agency — forty-four states offer some sort of review of denied insurance claims. However, these agencies are sometimes limited in the types of issues they can review.

Bad Faith Insurance Lawsuits

Should all these administrative remedies fail, it may be time for the claimant to enlist the services of a bad faith insurance lawyer. Filing a bad faith lawsuit gives a claimant much more leverage against a bad faith denial, and it lets the insurer know the claimant isn’t going to take the denial sitting down.

Join a Free California Bad Faith Insurance Lawsuit Investigation

A bad faith lawsuit investigation has been launched into allegations that some California insurance companies are refusing to pay valid medical claims or offering to pay far less than the claim is worth. Some of the companies being investigated for potential violations include:

• Aetna
• Anthem Blue Cross
• Blue Cross of California
• Blue Shield of California
• Cigna
• Health Net
• Kaiser
• Secured Horizons
• United Healthcare
• WellPoint
• Others

If you or a loved one were denied coverage for autism treatment, mental health treatment, plastic surgery skin removal after weight loss, proton therapy for cancer, or some other medically necessary treatment, you may have a legal claim.

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