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What to Do When Health Insurance Won’t Pay

Male patient angry at expensive healthcare bill

Health insurance claims are denied for a host of reasons, good and bad. Your claim might not be covered by your policy, you may have left out some important documents or supporting information, or your insurance provider could be denying your claim in bad faith even though it should be covered. If your health insurance claim was denied, there are a few helpful steps to take. Reach out to a dedicated Los Angeles health insurance denial lawyer for help regarding a California health insurance claim.

Review the denial letter, and carefully review your insurance policy

The first thing to do when a claim is denied is to carefully review the provider’s reason for denial and your insurance policy. Make sure that you understand your coverage and that your condition and the treatment you received or seek are covered. The insurance company might have interpreted a coverage provision differently than you. Respect your own judgment: If you feel that the insurance company is being unfair with their interpretation, there is a good chance that you are right.

Ask your insurance agent or HR department for help

You might be able to get some guidance from the agent who sold you the insurance or from the health benefits manager in your human resources department, if your policy is through your employer. They may be able to help you understand the denial, clarify your policy coverage limits, and they might even be willing to reach out to the insurer on your behalf if you and they agree that the insurance provider made an error.

Call the insurance company

Mistakes happen. It is possible that your insurance provider misunderstood your claims or the policy coverage, that there was an administrative or clerical error, or that they are simply missing some detail or documentation that would make your claim go through. You might be able to resolve the matter by providing some additional documentation or clarifying some piece of information about yourself, your treatments, or your condition.

Appeal the claim

If you cannot get a straight answer from your insurance company, or if they refuse to change their decision, then you have the right to appeal the denial. The Affordable Care Act (ACA) grants you the right to appeal your denial internally within the insurance company, securing an official re-review of their decision. If they still deny your claim, you also have the right to an independent external appeal. Appeals are permitted both before and after service. If you need treatment and coverage immediately due to an emergency or other extenuating circumstances, you might be able to request expedited review.

Get a lawyer

At any stage after your health insurance claim has been denied, it is helpful to reach out to an experienced insurance denial attorney for advice and representation. An attorney can help you evaluate your next steps and can handle communications with your insurance company for you. They will help you decode the legalese in your policy to ensure that your claim should be covered, and prevent the insurance company from giving you the run-around. If you ultimately need to appeal the denial, your attorney will help you gather the appropriate documents, prepare your appeal letter, and work through the appeals process.

Call For Help With Your California Health Insurance Claims

If you are facing legal issues concerning your California health insurance policy or a dispute over claim coverage, get compassionate and effective help ensuring you get the coverage you deserve by contacting the Los Angeles insurance claim denial lawyers at Gianelli & Morris for a free consultation at 213-489-1600.

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