What To Do When Insurers Deny A Medical Or Health Benefits Claim
You have employer provided health or medical insurance. You have a plan booklet – maybe – that is mostly incomprehensible. Your health and medical insurance company commonly pays for routine medical care without any problems. But then, you or a family member need or has an expensive surgery or needs expensive prescription medication or are hospitalized or need special treatment and your health insurance company won’t pay.
Health insurance companies deny claims all the time. Usually all you get is a brief document known as an “Explanation of Benefits” which provides a number code as the reason for the claim being denied. In turn, the number code is briefly explained in small print in the document. Often the reason stated is “not medically necessary” or “experimental” or “not covered,” or something similar that means nothing to you. Usually there is a brief explanation on the form that you have the right to appeal that decision and usually you have a right to pursue “an external appeal” if the internal appeal to the insurance company is denied. Sometimes, your doctor will submit an appeal on your behalf, for example explaining why the treatment or the medication is medically necessary or not experimental. But often, even your doctor’s explanation is not enough: the claim is still denied. So, to get the benefits to which you are entitled, you have to sue. The lawyers at the ERISA Law Center have extensive experience pursuing claims in federal court under the Employee Retirement Income Security Act (ERISA), which governs most employer-provided health and medical insurance policies and plans. We have successfully sued insurers for denying legitimate medical and health benefits claims. If your health or medical insurance claim is denied and you need legal assistance, the lawyers at the ERISA Law Center can help you obtain your rights. Call our office at 866-360-0983, 559-549-6490 or send us a message online.