Health Care Plan Disputes
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What Are Health Care Plans?
Health care plans exist to provide consumers with medical care packages and insurance plans. There are many different types of health care plans (also called health insurance or simply, health care). For example, they can be obtained through private health plan companies, through coverage provided by an employer, or through government assistance programs.
While health care plans can be very helpful, they are often a common source of disputes, and result in a considerable amount of lawsuits every year.
What Are Some Common Health Care Plan Disputes?
Health care plan disputes may involve a number of different factors. Some common health care plan disputes include:
- Denial of medical coverage for services or benefits
- Refusal to authorize the insured person’s hospital visit or medical procedure
- Incorrect charges for medical services
- Cancellation of health insurance policies without any notice
- Refusal to carry over a policy when changing jobs
Disputes over health care coverage or polices can therefore involve many different parties: the insured, the policy providers, employers, medical companies, etc. However, most health care plan disputes involve direct claims between the insured and the policy provider.
How Does Obamacare Factor Into This?
In 2010, the federal government passed the Affordable Care Act, otherwise known as Obamacare. Obamacare is a massive healthcare insurance reform bill, adding several layers of new rules to already complex insurance law. Obamacare’s major changes to health care plan law are:
- Making it illegal for insurance companies to deny services based on pre-existing conditions.
- Creating a list of benefits that an insurance company must provide as part of their health care plans, including birth control.
- Forcing employers with a certain number of employees to provide health care insurance.
- Creating minimum standards for out-of-pocket payments.
- Permitting children to stay on their parents’ health care plan until the age of 26.
What Steps Can I Take If I Have a Health Care Plan Dispute?
If you are involved in a dispute over your health care plan, there are certain steps that you can take in order to obtain a remedy for your situation.
Filing a claim for a health care plan dispute can be done in these basic ways:
- Obtain notice: If you were denied coverage or had your policy cancelled, be sure to get the denial/cancellation and the reasons for it in writing. There are two reasons. First, there are laws which require that insurance companies provide notice before denying services, so this may buy you some time. Second, it will be easier to review the decision in or out of court if you have paperwork detailing the insurance company’s reasoning.
- Internal Review: An internal review is basically a claim that is filed through the complaining mechanisms of the health care organization itself. No outside agencies are used for resolving the complaint. This is also known as a consumer complaint, in which the health care company will provide the insured with a remedy for their losses.
- External Review: This is where an outside agency reviews the complaint. External review may be necessary where an internal review cannot fully resolve the health care plan dispute. However, an external review is not always available for all claims. They are typically reserved for persons who are self-insured or who are insured through an employer-sponsorship program.
- Arbitration or Mediation: It is not unusual for an insurance contract to contain a clause like "any disputes will be submitted to arbitration" or "any dispute will be mediated before litigation." Generally, insurance holders don’t want to go to arbitration because the insurance companies have pre-chosen the arbitrator with no means of appeal. Mediation is fairer to consumers because the mediator has no legal power, but meditation can also be used simply as a means to delay trial.
- Civil Lawsuit: If the parties cannot reach an agreement through an internal or external review, it may be possible to file a lawsuit in a civil court. This will involve presentation of evidence and may require the testimony of expert witnesses. In severe cases, a lawsuit can be filed before a review is filed.
Whether you plan to resolve the dispute through review, arbitration, meditation, or a lawsuit, you’ll need to make sure you are thoroughly prepared to argue your claim. You will want to compile all the documents and information related to your claim. Most of all, be sure you understand your health care policy before you try to file a claim. You may wish to highlight or underline the important terms that you feel have been violated.
What If My Plan Was Cancelled Because of Obamacare?
Thousands of Americans have received notice, or will receive a notice, that their healthcare plan is being cancelled either because it fails to comply with the essential benefits provision or because it doesn’t comply with the minimum out-of-pocket expense provision. In either case, President Obama has signed an executive order extending the deadline for insurance companies to comply with those provisions of the Affordable Care Act.
Do I Need a Lawyer for Help With a Health Care Plan Dispute?
When filing a health care plan claim, it’s to your advantage to hire a lawyer for assistance. Your lawyer can review your policy and provide you with valuable advice according to the laws in your area. Experienced attorneys understand the various factors involved in health care plans, and can help you obtain legal relief for any losses you have suffered.
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Last Modified: 12-10-2013 05:00 PM PST
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