California Insurance Commissioner Dave Jones continues his advocacy for California consumers, this time by issuing a notice to insurers reminding them they are legally obligated to fully disclose to policyholders why a claim for treatment is denied. If the insurer says the reason for the denial is because the treatment is not medically necessary, the insurer is required to outline the facts and the law upon which it based the denial.
At the same time, Jones issued a consumer alert urging policyholders to challenge the denial because they have a legal right to appeal and they have a fair chance of winning the appeal. Consumers may also request the California Department of Insurance conduct an Independent Medical Review (IMR) of the denial.
Why did Commissioner Jones have to remind insurers to follow the law? His department investigates about 7000 health insurance-related complaints every year. He has seen, as we have, that many insurers fail to fully disclose the basis for the denial and may not make the policyholder aware of the facts that went into the decision and the law regarding how insurers must handle claims. In other words, they defy California consumer-protection laws.
Every day we help people confused by the lack of information their insurers made available when denying a claim. Many come to us because they don’t know the law and need help sorting through the stacks of paperwork that often don’t say much that helps our clients understand why they claim was denied. The need lawyers like us – and regulators like Commissioner Dave Jones – to hold insurers accountable.
“Denial by an insurance company is not the final word,” said Jones in a press release. We agree. Call us at (800) 446-7529 if you don’t want your insurer to have the final word. We can help.
For more information about how to request an IMR from the Department of Insurance, follow this link: http://www.insurance.ca.gov/0400-news/0100-press-releases/2012/release158-12.cfm.