Health insurance plans are types of insurance coverage which covers the insured policyholders from paying certain medical and surgical expenses. A health insurance plan with health insurance benefits is often necessary because, if an individual does not have it, the out-of-pocket expenses for medical emergencies are substantial.

Health insurance is able to cover, or pay a portion of the cost of, medical emergencies which are associated with an individual’s dental, vision, and other medical necessities. Depending on an individual’s health coverage, the costs may be paid in one of two ways:

  • The individual pays up front out-of-pocket and then is reimbursed for the cost; or
  • The insurance company pays the individual’s provider directly.

When an individual has health insurance coverage, they are required to pay the insurance company premiums in exchange for the insurance company paying their medical bills. The cost of insurance premiums will vary depending upon the individual’s coverage plan.

Is Health Insurance Mandatory?

Pursuant to health insurance laws at the federal level, health insurance coverage is not mandatory as of January 1, 2019. It is important to note, however, that some states still require individuals to have health insurance coverage in order to avoid paying a tax penalty. Although not having health insurance saves an individual money since they are not paying a premium, it may put them at a financial risk if they become injured or develop a serious illness.

What Should I Do If I Can’t Afford Health Insurance?

There are several options available if an individual cannot afford health insurance. One option may be subsidized health insurance. If an individual makes under a certain income level, there is a good chance they would qualify for a subsidy on the health care exchange.

A second option for individuals who cannot afford insurance may include a catastrophic health plan or short-term health plan. These plans are cheaper. It is important to note that they do not typically cover things like regular doctor visits, but they will protect an individual in the event that they have an accident or substantial diagnosis.

If an individual has little to no income, they may qualify through a governmental agency, such as Medicaid. Medicaid provides health coverage to may individuals, including:

  • Low-income adults;
  • Pregnant women;
  • Elderly adults; and
  • Individuals with disabilities.

Medicaid is administered by the states according to the requirements of the federal government.

Another possible alternative for individuals is Medicare. Medicare is a program for individuals who are elderly and/or disabled. In order to qualify for Medicare, an individual is required to:

  • Be over 65 years of age and eligible for social security or railroad retirement;
  • Be disabled; and, for the last two years,
    • have received social security; or
    • railroad retirement; or
  • Be over 65 years of age and pay for Medicare coverage.

Are There Laws to Protect Consumers from Health Insurance Discrimination?

Yes, there are various health insurance rules and regulations which protect consumers from health insurance discrimination. One of these is the Affordable Care Act, also known as the ACA or Obamacare.

Pursuant to the ACA, it is illegal for an insurance company to deny an individual insurance coverage based upon a pre-existing condition. In the context of healthcare, a pre-existing condition, or pre-existing illness, is an illness which an individual has prior to applying for their health care plan.

A pre-existing condition may include a chronic or long-term condition. In certain cases, pregnancy may be considered a pre-existing condition for the purposes of a health insurance policy.

In addition, pursuant to federal laws, an insurance company cannot deny an individual coverage based on their:

  • Race;
  • Color;
  • National origin;
  • Sex;
  • Age; or
  • Disability.

There are also other insurance rules, regulations, and laws which may apply. These include the Health Insurance Portability and Accountability Act (HIPAA) and the Employee Retirement Security Act (ERISA). These laws provide additional protections for employees who are insured and employees who are retired.

When do Health Insurance Disputes Arise?

There are a number of ways in which health insurance disputes may arise. Common health care disputes include, but are not limited to:

  • The denial of medical coverage for benefits or services;
  • Refusal to authorize the insured individual’s hospital visit or medical procedure;
  • Incorrect charges for medical services;
  • Cancellation of health insurance policies without any notice; and
  • Refusal to carry over an individual’s policy when they change jobs.

A health care dispute may involve multiple parties, such as:

  • The insured individual;
  • The policy provider;
  • The employer;
  • The medical company; and
  • Other interested parties.

In many cases, however, a health plan dispute involves a direct claim between the insured individual and their insurance company.

What can I do if I have a Health Care Plan Dispute?

If an individual has a health care plan dispute, they should file a claim against their insurance carrier. There are several basic steps which an individual should follow.

First, an individual should check their insurance agreement, including their Summary of Plan Description and Evidence of Insurance Coverage. It is important to ensure that the disputed claim is actually covered by the policy. An individual can contact customer service and request a reversal of the improper charge or coverage denial.

An individual’s insurance carrier should send the individual a denial of coverage or cancellation letter. This letter should include the reasons for the denial or cancellation. Insurance companies are required by law to provide notice prior to denying coverage.

If customer service is unable to help the individual reverse the improper charge or coverage denial, they should inform the carrier that they dispute the denial or cancellation in writing. The individual’s insurance carriers will begin an internal review process in order to determine whether or not they erroneously denied the coverage or cancelled the policy.

This process is called an internal review because there are no outside agencies that are used to resolve the complaint.

What are Other Remedies if an Internal Review is Unsuccessful?

There may also be other available remedies if an internal review is unsuccessful, such as an external review. An external review occurs when an agency outside of the insurance provider reviews an individual’s complaint. It is important to note that external reviews are usually available for individuals who are self-insured or who are insured through an employer-sponsorship program.

An individual’s insurance contract may have a mediation or an arbitration clause. These clauses will require that an individual’s dispute be resolved either by a binding arbitration or an attempt at reaching a resolution through mediation prior to filing a civil lawsuit.

If an individual’s insurance plan does not include a mediation or arbitration clause, or if a mediation is not successful in resolving the dispute, the individual may wish to file a lawsuit in civil court. A civil lawsuit requires evidence to be presented to a jury of the individual’s peers through testimony and expert witness testimony.

Should I Hire Legal Counsel?

Yes, it is essential to have the assistance of a healthcare attorney for any health care plan disputes you may be facing. Your attorney can provide advice regarding the health care laws and requirements in your area as well as review your existing health care policy. Your attorney can also explain the various factors which are involved in a health care plan and assist you with obtaining legal relief for losses you have suffered.