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Surgery Insurance Denials

Health insurance is designed to help the average person afford the costliest medical expenses. By and large, most of us need relatively little medical care until a major need arises. When those needs do come, such as a need for surgery to alleviate a painful condition, we should be able to trust that the insurance we’ve spent years paying into will help us afford the expenses related to the surgery. Sadly, it is a battle for many of us to get the insurance coverage for surgery that we need. This can lead to enormous out-of-pocket expenses or additional health complications when surgery is delayed or not performed.

Thankfully, help is available in the battle against bad faith insurers for health benefits. The dedicated and aggressive California insurance bad faith lawyers at Gianelli & Morris have dedicated themselves to helping policyholders get the health insurance benefits they’re entitled to receive. Contact our Los Angeles insurance denial lawyers today to begin the process of fighting a wrongful claim denial.

Lack of medical necessity often relied on for bad faith denials of claims for surgery

In our work as insurance bad faith lawyers, we see several types of claims for surgical procedures rejected again and again by California health insurance carriers. One frequently-rejected claim is for tumescent liposuction prescribed to treat lipedema. The average person might assume that liposuction could only be useful for aesthetic purposes. However, insurance carriers know that lipedema is a painful condition that can result in hardened tissues and joint pain if left untreated and that tumescent liposuction is one of the few, if not only, effective treatments available for this condition. Nevertheless, insurers deny these claims for lack of medical necessity, suggesting that patients only want the aesthetic benefits of liposuction despite evidence from doctors explaining the medical need for the procedure.

Insurers are also slow to approve claims for modern spinal surgeries such as Artificial Disc Replacement, or ADR. While these more advanced procedures may be more costly to perform, they’re more likely to be successful for many patients with spinal injuries or degenerative diseases. Insurers see the request for these surgeries and stamp “denied for lack of medical necessity” without looking closely at the patient’s unique circumstances.

Failure to conduct an individual review of surgical requests could indicate bad faith

If insurers deny surgery claims for all patients seeking one particular procedure, this implies that the insurers are not conducting a careful, individualized review of each patient’s condition and needs. This could be evidence of the insurer’s lack of good faith and fair dealing when considering patient claims. In fact, a number of insurers, including Aetna and Humana, were forced to enter into a class action settlement agreement with doctors across the country due to their repeated denial of surgical claims without first reviewing the individual patient’s file. Victims of bad faith insurance denials could be eligible for delivery of the benefits available under their policy, as well as possible monetary damages for the insurer’s violation of the laws on good faith and fair dealing. The knowledgeable California health insurance denial lawyers at Gianelli & Morris can help you determine if you have a bad faith claim against your health insurance provider.

Talk to a Lawyer about An Insurer’s Denial of Your Request for Surgery

For seasoned, compassionate, and professional legal help after a California health insurance claim denial, contact the dedicated and effective Los Angeles bad faith insurance lawyers at Gianelli & Morris for a free consultation at 213-489-1600.

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