Health Insurance Disputes

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 What Is Insurance Law?

Insurance companies are regulated by the Department of Insurance present in each state. As such, insurance lawyers are lawyers that represent people who have had a legitimate insurance claim denied, or who have been subjected to a company’s act of bad faith. Insurance law addresses numerous different legal issues, such as insurance fraud or where an individual is refused coverage that is their legal right.

There are numerous different types of insurance available to consumers. Although some insurance coverage is required by law, such as car insurance, others insurances are optional. Health Insurance is one such type of insurance coverage that is optional for an individual. Importantly, some states do require an individual to carry health insurance, or else they will face tax penalties.

What Do Health Insurance Plans Provide?

Once again, health insurance plans are types of insurance coverage that provide coverage to the insured policyholders. Health insurance plans essentially pay certain medical and surgical expenses that are covered by the plan. Health insurance plans are often necessary because, if an individual does not have a plan, the out-of-pocket expenses related to a medical emergency can be substantial.

Health insurance plans are able to prevent the insurance policyholder from paying portions of the costs associated with their medical emergencies and medical treatment. Health insurance plans typically can cover an individual’s vision, dental, prescription medications and other medical treatments. As far as obtaining health insurance plans, there are typically three different ways of obtaining a health insurance plan:

  1. The individual acquires the plan through a private or government sponsored health insurance marketplace;
  2. The individual is covered by their state’s Medicaid or Medicare program(s); or
  3. The individual is provided a health insurance plan by their employer as a benefit to working at that company.

When Do Health Insurance Disputes Arise?

As mentioned above, a health insurance dispute may arise when a health insurance company refuses coverage, declines to cover certain medical procedures, or charges an individual unaccountable fees. A health insurance dispute may also arise in cases of health insurance fraud.

It is important to note that before resolving a health insurance dispute formally, the policyholder may seek informal solutions by contacting their insurance company directly. Seeking an informal resolution will enable the policyholder to collect important information for a potential legal action.

Specifically, in the case of a health insurance denial, an individual may be able to appeal their insurance provider’s denial of benefits directly with their provider. However, if the provider still refuses to cover the treatment, then the policy holder could then initiate civil action against the insurance provider.

How to Address a Dispute with a Health Insurance Company

As mentioned above, if an insured’s coverage has been denied or an improper charge has been applied to their account, they may first ask their insurance company to review the matter. This process is meant to allow the insurance provider an opportunity to correct their mistakes through an Internal review and appeals process that may efficiently resolve the error.

However, if the policy provider does not resolve the dispute through their internal appeals process, then the policy holder is able to sue a health insurance company. Specifically, the policy holder may sue their policy provider to cover the costs associated with certain medical procedures or refund/cancel charges made to the policy holder.

Preliminary Considerations for an Internal Review

Before initiating an internal review with an insurance provider, an insurance policy holder should complete the following steps:

  • Review Their Insurance Agreement: First, a policy holder should be aware of everything that is covered in their health insurance plan before lodging a complaint for a medical procedure not being covered.
    • Reviewing the insurance agreement should include reviewing the Summary of Plan Description and the Evidence of Coverage in particular;
  • Contact the Insurance Provider Directly: Next, an insured party should contact the insurance provider’s customer service and ask for the reversal of an improper charge or coverage denial to be reviewed;
  • Develop a Record: Next, the insured party should develop a written record of all the documents and conversations that relate to their legal dispute; and
  • Request a Denial Letter: After exhausting all possible administrative remedies through the policy provider themselves, the insured party should request a formal letter of denial from the insurance company, which can be used to initiate a civil lawsuit against the policy provider.

It is important to note that many internal appeals have a time limit in which an appeal of a wrongful charge or denial must be made. As such, it is important to make sure to file for an internal appeal within the appropriate deadline. If the deadline is missed, an insured’s internal and later external appeal rights may be jeopardized.

How to Support Your Position in the Internal Review Process

In order for an insured to support their arguments in the internal review process, they may consider preparing and submitting the following materials to the policy provider for the insurance evaluation:

  • The relevant sections and provisions from their Evidence of Coverage;
  • Their doctors’ explanations of why their condition should be covered;
  • Opinions of other doctors regarding their medical condition and treatments;
  • Billing statements and other documents that evidence payments;
  • Any additional information about their medical condition;
  • Information on treatment of their medical conditions; and/or
  • Any and all explanation of benefits forms.

It is important to note that consulting with an experienced health insurance dispute attorney may be beneficial in timely resolving any disputes in the internal review process.

The Actual Internal Review Process

As far as the actual internal review process, the process for appealing an insurance decision will typically be outlined in the explanation of benefits forms provided to the insured. Regarding the actual internal review process, there are several things an insured should keep in mind:

  • If the first internal review is not successful, they may be able to apply for a second internal review.
  • The second internal appeal may involve a panel, committee, or an in person hearing;
  • If the second review process involves an in person hearing, the insured may be required to attend and present evidence of their medical conditions and coverage.
    • Once again, an experienced health insurance dispute attorney may be beneficial in representing an insured at an in person proceeding; and
  • An arbitration clause may be included in the insurance contract, which may also take place in addition to the typical internal review process.

After an insured person files an internal review, the insurance company must respond within a certain time. The insured’s Evidence of Coverage will typically tell them the specific timeframe in which the policy provider must respond by. However, in cases where the insured is in danger of suffering adverse health effects, they may ask for an expedited response, such as responding within 72 hours.

Once again, if the internal review process by the insurance policy holder is not successful, then the insured may still privately sue their insurance provider to pay for a denied health claim or reduce or eliminate charges made for covered procedures.

Seeking Legal Help

As can be seen, disputes with health insurance companies are often complex and an insured’s rights may depend on wordy provisions that are present in their health insurance contract. Additionally, state laws and local laws may also specify how an individual is supposed to make a health insurance dispute claim. Failure to follow the rules outlined by the policy or state, may result in an insured not being able to recover for a denied health claim or charges made against them.

As such, if you have a health insurance dispute, it is in your best interests to consult with an experienced insurance lawyer.

An experienced health insurance lawyer will be able to assist you in internally appealing the decision of the insurance provider. Additionally, should a private legal claim become necessary, an insurance lawyer will be able to initiate the private civil claim and represent you in court, as necessary.


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