On January 13, 2017, the Los Angeles Times published a column entitled Healthcare insurance hell: If at first your claim is denied, try, try again
The article describes on insured’s extreme difficulty in obtaining approval for treatments of her multiple autoimmune disorders that cause chronic pain, migraines, extreme dizziness and debilitating chronic fatigue. As the title shows, the main thrust of the argument is to never give up if your health insurance claim is denied – however, this advice is not only applicable to health insurance claims – the same holds true, believe it or not, for Long Term Disability, Long Term Care, and even Life Insurance claims!
Some interesting additional information is also included in the column:
- “A 2011 study by the California Nurses Association estimated that the state’s top insurers rejected about 26% of all claims.” http://www.prnewswire.com/news-releases/california-insurers-continue-to-deny-26-of-all-claims-114945379.html
- “A separate study that year by the Government Accountability Office found that denied claims were reversed in about half of all appeals, for those with the stamina to work the system.” http://www.gao.gov/new.items/d11268.pdf
- A representative from Consumer Watchdog explained that since insurance companies can no longer deny individuals with preexisting conditions, they have had to find other ways to not pay claims. “Their main tactic is to deny everything and hope the consumer won’t put up a fight. They know the consumer usually won’t.”
What the article doesn’t discuss is when it is a good idea to enlist help from an attorney. In regard to group Health, Life, Disability, and Long Term Care claims, governed by the Federal laws under ERISA, there are very restrictive evidentiary rules. So, what you submit during your administrative appeal may be your last opportunity to provide evidence before litigation. Hiring an attorney to handle your appeal might be the difference between winning and losing at trial, as attorneys who focus exclusively in this area of law are in the best position to know what evidence will get your claim paid. And unbeknownst to many insureds, such attorneys will often offer free consultations, and/or handle the case on a contingency basis- so you won’t have to go out of pocket to get the help you need.
We are always available to answer your questions! (877) 783-8686