Claim Denial from an Insurance Provider
Understanding Health Management Organizations
One of the most common types of managed care
insurance systems is the Health Maintenance Organization (HMO). This type of service
provides the consumer with general health and wellness benefits including
annual physical exams and gynecological appointments for women. Any other
medical need outside of this general covering must first go through your
general practitioner. The Primary Care Provider (PCP) is the physician
who can refer you to specialists outside of basic medical issues such
as x-rays or lab tests.
If you fail to receive a referral, you must pay the specific doctor the
amount for the service rather than the discounted copay. There is a yearly
premium that is paid for by the consumer as well as copayments for each
and every visit to doctors under the HMO umbrella. People find this type
of health care insurance to be profitable because costs are more dependent
upon your need for medical help thereby allowing it to be the most affordable plan.
What if my claim is denied?
According to California Health and Safety Code §1340, it is illegal
for an HMO to wrongfully deny any legitimate claims or wait unnecessarily
long to approve a referral for medical care. Often you can personally
dispute the case with the HMO directly, but this can prove futile on occasions
where they are purposefully neglecting your medical needs. It may be difficult
to determine what chance you have of receiving the necessary coverage
unless you speak to a lawyer. At our firm, we have handled a large number
of cases and lawsuits dealing with issues such as this. Before you give
up, allow one of our qualified Los Angeles insurance attorneys to talk
with you about the options you have.
Los Angeles HMO Dispute Attorney
Having been in the legal field since 1979, we have a qualified legal team
that is ready to help you in disputing your denials. They can figure out
if your case is against the HMO or if there needs to be a lawsuit filed
against the physician. There are a myriad of settlements that can occur
as a result of negligence on behalf of the HMO, but sometimes they have
nothing to do with the way in which a doctor has provided care. When you
have legal representation by your side, they can sift through the laws,
investigate the issue at hand and determine what would be most profitable for you.
Contact our firm today to learn what we can do for you!