To avoid paying an unexpected bill because of a denied medical claim, you’ll need to take on your insurance provider and fight for an appeal. Going up against a powerful health insurance company can be intimidating, though, so should you get a health insurance lawyer involved? Read on to find out!
What is a Health Insurance Claim Denial?
Health insurance claim denials are when your insurance chooses not to pay for a medical service you received. This can happen for a variety of reasons—maybe you saw an out of network provider, underwent an experimental procedure, or missed a deadline to submit your claim.
Often a health insurance denial will come as a surprise. Suddenly, you’ll be responsible for paying an expensive bill for a medical service that your doctor recommended as part of your care. Since health insurance companies are run like businesses, you know they will do everything in their power to insist the claim isn’t covered by your policy.
So what options are within your power to fight back? Should you seek out an insurance denial attorney right away?
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How Do You Fight a Health Insurance Claim Denial?
No matter the reason for your medical claim denial, the first step toward getting the decision reversed is to file an appeal. This typically means filling out paperwork to submit to your health insurance that requests they take another look at your claim.
Filing a health insurance claim appeal is easier said than done. Sometimes you need to start with an internal appeal (this goes through your health insurance company’s review team) as your first course of action, and sometimes you can jump right over their heads to get the claim reviewed by your state government.
With some insurance providers, filing an appeal just means submitting an official request, but with others the process requires paperwork from your doctors and additional evidence that the claim was wrongly denied. But how do you as an individual know where to start in all this mess, and how can you possibly stand up to a multi-million dollar company?
Can a Lawyer Fight My Denied Claim?
When looking ahead to a tough fight against a health insurance denial, many people immediately call in an insurance denial attorney. While there are lawyers who specifically deal with health insurance claim denials, often the denials can be reversed with easier alternatives that are also more affordable!
When to Hire a Health Insurance Denial Attorney
The health insurance appeal process is so complicated and time-consuming that it helps to know at what point you should bring in outside help. Here are a few scenarios in which it makes sense to hire a health insurance denial attorney or seek help from an expert:
- When you desperately need care. If you are facing a serious medical crisis that requires ongoing and immediate care, but your treatment was denied by your insurance company, it’s time to bring out the big guns. Taking legal action against your insurance provider might speed up the process so you can get coverage for the medical services you need.
- When your coverage was terminated without you knowing. Insurance companies are required by law to let you know promptly if they are ending your coverage. So if you are shocked to receive a claim denial with the reason that you were no longer covered by that company, it is possible that your insurance company broke the law. That’s when a health insurance denial attorney comes in handy.
- When your insurance company has taken too long to come to a decision. If you request an internal appeal of a denied claim, your insurance company has a certain timeframe in which they are required to respond. If that time has passed and you still haven’t heard from your insurance provider, you may need to seek help to compel them to make a decision.
- When a claim has been denied in bad faith. In the US, health insurance providers are legally obligated to operate at certain standards. When they don’t meet those standards, you may be able to sue them for denying a claim in bad faith.
What is Health Insurance Bad Faith?
Sometimes health insurance claim denials are just the result of simple errors, missed deadlines, or missing paperwork. But if your claim was denied because your health insurance didn’t follow its policies or the law, that is called bad faith. Examples of bad faith include:
- Denying claims that they did not properly investigate
- Giving you the wrong impression of their policy or misinterpreting it on purpose
- Denying claims without giving a valid reason
- Not communicating properly about coverage or claim denials
- Delaying the payment of a legitimate claim
If you believe that your insurance provider is guilty of any of the above, you may have a case for a bad faith lawsuit. A health insurance denial attorney can help you decide if it makes sense to sue.
Pros and Cons of Fighting Health Insurance Denials With Lawyers
Here are a few things to keep in mind when considering hiring a lawyer to tackle your denied medical claim:
Pros
It takes most of the burden off of you. When using a health insurance denial lawyer in the fight against giant insurance companies, you can submit all your evidence, receipts, and paperwork to the lawyer and let them take care of the complicated process. They will be experienced in dealing with medical claim denials and will know the ins and outs of health insurance laws. If you need representation in court, your insurance denial attorney will be there.
It shows your insurance provider you mean business. Health insurance companies will take a denied insurance claim lawyer more seriously than they will a policyholder (that means you). By threatening to file a lawsuit or take other legal action, you might scare your insurance company into appealing your claim right away.
You might get more than just a reimbursement. If you sue your insurance company for acting in bad faith, you might be able to win damages in addition to reimbursement for the claim. This depends on the grounds you have for the lawsuit and how serious your insurance provider’s misstep was. A health insurance denial attorney will try to squeeze the most money possible out of a lawsuit, which may mean winning more than the value of the claim.
Cons
Going to court. A court case is often a long, drawn-out process that requires a lot of energy. If you are suing your insurance provider for acting in bad faith, you may have to wait months, or even years, for an outcome. This strategy of fighting a health insurance denial requires a lot of patience on your part.
An attorney may not take your case. It’s also important to know that a health insurance denial attorney may not want to take on your case. Depending on the size of the claim, the grounds you have to sue or take legal action, and the details of your case, a health insurance denial lawyer may or may not choose to represent you. Unfortunately, you can’t always count on a lawyer’s help with a denied medical claim.
It’s expensive. Especially if you are fighting over a medical bill that is under $1,000, you’ll end up spending more money on the fight than you’ll get if you win the case. Lawyers typically demand an up-front sum plus hourly payments and additional fees. For most health insurance claim denials, this simply isn’t worth it.
Alternative Solution to Hiring a Health Insurance Denial Attorney
So what do you do when you need help fighting a health insurance denial? Reach out to aJust! Our experts pack the knowledge and experience of health insurance denial attorneys into a straightforward process with no hidden fees. In fact, if you don’t win your case, you don’t owe aJust anything.
Getting help from aJust when fighting a medical claim denial gives you the same peace of mind and same chances of a positive outcome as hiring a health insurance denial attorney, without all the extra fees! Because we know how hard it is to take on the insurance companies alone, and what’s at stake if you can’t reverse a health insurance denial.
$15k+ Medical Bill and No Luck With Lawyers
To show you what can happen if you seek out the help of a health insurance denial attorney, we thought we’d mention the story of a real aJust customer—we’ll call him by his initials, J. R.
By the time J.R. reached out to aJust for help, he had racked up a denied medical claim bill of over $15,000. In his desperation to get this medical bill covered, J.R. started looking for health insurance lawyers that could help him fight his insurance provider for coverage. The first denial attorney J.R. spoke to immediately refused to take on his case, so he searched for another. Ten health insurance denial attorneys later, J.R. was still stuck with an expensive medical bill and a whole lot of disappointment that no lawyer had shown interest in helping him.” J.R
That’s when J.R. found aJust. He completed the quick online form and received a call from aJust right away. Now, his appeal case is processing thanks to quick action on the part of the expert aJust team. Not only was he relieved that his case against the insurance provider wasn’t hopeless, but he was also ecstatic to have saved a bunch of money in lawyer fees!
