Report: Patients Who Appeal Bad Faith Insurance Claim Denials Often Win

Sometimes a patient’s claim for a healthcare service can be improperly denied. The Affordable Care Act has created a national standard for a patient’s right to appeal an insurance claim denial.

In an example of an appeal of a denial, an Arizona man was forced to appeal his insurance claim denial over treatment for sleep apnea.

Though the condition is in most cases fairly low-risk, it had actually become life-threatening in this man’s case. His sleep apnea had become so bad that he fell asleep behind the wheel, which he says is not something that ever happened before he developed the condition.

While the man’s doctor wanted him to go to a lab and undergo a sleep study test for his sleep apnea, his insurance company denied the test.

The insurance company insisted that this sleep apnea test was not “medically necessary” for the patient, and kept sending denial letters despite his attempts to get approval.

Appealing Insurance Claim Denials

Only about three percent of insurance claims are denied in the first place. After that, patients have a fairly good chance of having their appeal go through successfully.

Approximately half the time a patient in California appeals an insurance claim denial, the patient wins, according to Capital Public Radio.

According to a 2011 GAO report, this statistic is fairly consistent nationally.

The GAO report took a sampling of data from several states across the country even before the implementation of the Affordable Care Act. Under these circumstances, patients’ appeals directly to the insurer over insurance claim denials were successful 39 to 59 percent of the time.

When patients appealed to a third party, they were also often successful. In some states, patients were successful in their appeals to a third party (such as the state insurance commissioner) about 50 percent of the time. In others the success rate was lower, such as 23 percent in Ohio.

The ability to appeal insurance claim denials is a very important protection for people, according to Cheryl F., Director of Families USA. Families USA is a nonprofit private insurance program. “It’s often very worthwhile for a consumer to appeal,” Cheryl said.

“Insurers often get it wrong the first time,” she added. “So if you’ve been denied a health care service, it might be because the plan didn’t understand why that service was needed and why it fit their guidelines.”

There is also the possibility that a patient received an unfair insurance claim denial because of a simple administrative error.

However, other insurance claim denials are filed not because of computer or data entry errors but because of judgments of medical necessity, such as the case of the Arizona man with sleep apnea. In these cases, an insurer may consider a treatment experimental and therefore not proven to be medically necessary.

According to insurers, their decisions about the medical necessity of certain treatments are supported by medical studies. If a treatment has a great deal of evidence that it is both appropriate and effective, then it is more likely to be covered.

Bad Faith Insurance Lawsuits

Some consumers who have been denied their legitimate insurance claims have responded by filing bad faith insurance lawsuits. These insurance lawsuits allege that insurance companies may deliberately deny legitimate insurance claims in order to boost their own profits.

Many disappointed consumers with legitimate disability insurance claims are filing bad faith insurance lawsuits, hoping to eventually reverse their insurer’s claim denial.

More and more people that have been denied disability insurance are coming forward with their personal stories in these claim denial cases. Some injured parties have decided to file bad faith lawsuits, gaining thousands or in some cases even millions of dollars in settlement money.

If you or someone you know has been denied long term disability insurance or other insurance, you may be able to file a bad faith insurance lawsuit.

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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