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What are Health Insurance Plans?

Health insurance is a type of insurance coverage that covers its insured policyholders from paying various medical and surgical expenses. Health insurance plans are often necessary because without it, out-of-pocket expenses for medical emergencies are prohibitively expensive. Health insurance can cover medical emergencies associated with your vision, dental, and other medical necessities. Depending on your health coverage, you may either pay out-of-pocket then are reimbursed for your expenses, or your insurance company pays your provider directly.
 
When someone has insurance coverage, they pay the required company premiums in exchange for the insurance company paying the insured’s medical bills. The cost of insurance premiums vary depending on your coverage plan.

When Do Health Insurance Disputes Arise?

Health insurance disputes can arise in any number of ways. Below are some common health care disputes:

  • 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

Health care disputes can involve multiple parties (the insured, policy providers, employers, medical companies, etc.). Notwithstanding, most health plan disputes involve direct claims between the insured and the insurance company.

Are There Laws to Protect Consumers from Health Insurance Discrimination?

Yes. The Affordable Care Act (the ACA or “Obamacare”) made it illegal for insurance companies to deny someone coverage based on pre-existing conditions. In the healthcare context, a pre-existing illness, also known as a pre-existing condition, is any illness a person has prior to applying for a health care plan. Pre-existing conditions can include chronic or long-term conditions. In some cases, pregnancy can also be considered a pre-existing condition for health policy purposes.
 
Further, pursuant to federal law, insurance companies cannot deny you coverage based on your race or color, national origin, sex, age, or disability.
 
Other insurance laws, rules and regulations can also apply, including the Employee Retirement Security Act (ERISA) and the Health Insurance Portability and Accountability Act (HIPAA). These laws provide additional protections for insured employees and retired employees.

What Can I Do if I Have a Health Care Plan Dispute?

If you have a health care plan dispute, you should file a claim against your insurance carrier. These are the basic steps.
 
Check your insurance agreement, including the Summary of Plan Description and Evidence of Insurance Coverage. Make sure that your disputed claim is actually covered. Contact customer service and ask for the reversal of an improper charge or coverage denial.
 
Your insurance carrier should send you a denial of coverage or cancellation letter. The letter should include the reasons for denial/cancellation. By law, insurance companies must give notice before denying coverage.
 
If customer service is not able to help you reverse the improper charges or coverage denial, inform your carrier to dispute the denial or cancellation in writing. Your insurance carrier will begin an internal review process to determine whether they erroneously denied coverage/cancelled your policy. This is known as an internal review because no outside agencies are used for resolving the complaint.

What are Other Remedies if An Internal Review is Unsuccessful?

If an internal review cannot resolve the dispute, an external review may be necessary. An external review occurs when an outside agency reviews the complaint. Note that external reviews are typically available for people who are self-insured or insured through an employer-sponsorship program.
 
Your insurance contract may have an arbitration or mediation clause. The clause requires that your dispute be resolved either in binding arbitration or attempt resolution through mediation before filing suit.
 
If your insurance plan does not have an arbitration or mediation clause, or if mediation proves unsuccessful in resolving your dispute, you may want to file a lawsuit in civil court. A lawsuit requires the presentation of evidence to a jury of your peers through testimony and expert witnesses.

Should I Hire Legal Counsel?

When filing a health care plan claim, you may wish to hire a lawyer for assistance. Your lawyer can review your policy and provide you with invaluable advice regarding the specific health care laws in your area. Knowledgeable healthcare attorneys understand the various factors involved in health care plans, and can help you obtain legal relief for any losses you have suffered.

Photo of page author Erin Chan Adams

, LegalMatch Legal Writer

Last Modified: 11-02-2017 01:29 PM PDT

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