Sometimes, health insurance companies deny valid claims. Policyholders may appeal such adverse benefit determinations, first to the insurance company’s internal appeal board and then to an independent party for external review. Those who believe they received an unjustified denial may be able to sue their health insurance company in a bad faith lawsuit to recover damages.
Common Reasons for Denial
Policyholders must first file an appeal with their health insurance company, which will then conduct its own internal review. Common reasons insurance companies cite for denial are that the requested service:
- Is not covered under the policy
- Was not provided by an in-network health provider or facility
- Is not medically necessary
- Is specifically excluded under the policy
The Appeals Process
Adverse benefit determinations must be appealed within six months. Insurance companies are required to give each appeal a full and fair review; therefore, policyholders can present evidence to support their claim. There are specific timelines that apply depending on the circumstances of the claim, such as whether the treatment was already administered or whether the underlying medical issue is urgent.
Those who were denied coverage based on whether the care was medically necessary, where the care was administered, what types of care are available, and rescissions of coverage may request an external review. An independent review organization (IRO) will review the claim, along with supporting documentation before making a final decision.
Evidence to Support a Health Insurance Coverage Denial
In bad faith litigation, evidence must be introduced to support the claim. The type of evidence required varies, including that a valid claim was denied without reasonable basis. If a court finds that the insurer acted in bad faith by denying coverage, it may award the claim amount plus interest, as well as punitive damages against the insurer, and court costs and attorney’s fees. Some types of evidence that is important for policyholders to support their claims include:
- Correspondence: It is important to keep records of all correspondence with the insurance company. Keep dated, detailed records of phone and in-person conversations, as well as copies of all written communication.
- Contact information: Maintain a list of the names and contact information of all interested parties, including insurance agents, adjusters, and medical providers. These parties may need to provide supporting testimony at trial.
- Expert witnesses: It may be necessary to have an expert witness testify as to the medical necessity of the requested service. Their testimony may also be used to prove that the insurance company acted in bad faith.
Pittsburgh Insurance Lawyers at AlpernSchubert P.C. Help Clients with Health Insurance Coverage Appeals
If your health insurance claim was denied, contact a Pittsburgh insurance lawyer at AlpernSchubert P.C. Our experienced attorneys will help ensure that all supporting evidence is filed in your case, so you receive the benefits you deserve. For a free consultation, please complete our online contact form or call us at 412-765-1888. Located in Pittsburgh, we proudly serve clients throughout western Pennsylvania, including those in Allegheny County, Lawrence County, and Washington County.