News & Articles
Report Blasts Anthem for Denying ER Service and Treatment
The California Department of Managed Health Care (DMHC) conducts routine surveys of every California health care service plan at least once every three years, examining such factors as how each plan addresses customer grievances, how it makes health care services available, and the access to and payment for emergency services that it provides to… Read More »
Why Claims Get Denied: Medical Necessity
Recently, we published an article on denials of claims for health insurance benefits as “experimental,” one of the most-commonly-used excuses for the denial of a health insurance claim. Another commonly-provided reason for California health insurance claim denials is that the sought-after treatment is not medically necessary. Like denials based on the alleged experimental nature… Read More »
Can You Sue Your Insurance Company for Taking Too Long?
Recovering fully from a severe illness can be a race against the clock. Once your physician has diagnosed your condition and determined the best course of treatment, you naturally want to start that treatment as soon as possible. Most medical conditions will get worse without treatment, and some can even go from treatable to… Read More »
Insurers’ Duty to Investigate Claims Prior to Denial
When you submit a claim to your California health insurance provider, that insurer must carefully examine your claim before approving or rejecting it. Even when the claim is for coverage of a new or nontraditional procedure, your insurer has a responsibility to consider why it might be the best course of action in your… Read More »
When Can a Health Insurer Cancel an Insurance Policy in California?
If you or a member of your family is going through a health crisis, there are few pieces of news as devastating as hearing that your health insurance policy has been canceled. Abruptly losing your insurance can mean that you’re forced to pay out of pocket for costly treatments, if the necessary procedures are… Read More »
Does Egan’s “managing agent” rule survive 40 years later?
Most Insurance Bad Faith Cases Involve A Fight Over The Managerial Status Of The Employees Who Denied The Insured’s Claim Forty years ago, the California Supreme Court upheld a punitive-damage award against an insurer based on the acts of a claims adjuster in denying a single claim. Because the adjuster had the authority to… Read More »
Blue Shield is Overcharging Policyholders in Violation of California Law
Maintaining continuous health insurance coverage is critical, especially if you or other members of your family have a serious health condition. In the current market for health insurance, premiums are subject to rise a substantial amount each year, sometimes making policyholders’ current plans unaffordable for the following year. Policyholders are entitled to written notice… Read More »
Gianelli & Morris File Class Action Complaint Against Aetna for Refusal to Cover Medical Procedure
Insurer says procedure is “experimental and investigational,” despite years of FDA approval and countless successful operations On August 7, 2019, attorney Robert Gianelli filed a class action complaint in the United States District Court for the Central District of California alleging insurance company Aetna breached a duty to its policyholders by refusing to pay… Read More »
Claim Denials Based on “Experimental” Treatments
When insurance companies get it wrong, Gianelli & Morris makes it right Health insurance providers rely heavily on three reasons for denying their insured customers’ claims for health care benefits: that the sought-after treatment is experimental, that it is investigational, or that it is not medically necessary. Often, these reasons for claim denial are… Read More »
Anthem Blue Cross Receives Hefty Fine for Failures in Handling Customer Complaints
Anthem Blue Cross, one of California’s largest providers of health insurance, has recently reached a settlement with the California Department of Managed Health Care (DMHC) to address major flaws in its handling of customer complaints. Anthem will now be compelled to spend over $11 million in fines and investment in improving the customer grievance… Read More »
