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Category: Health Insurance

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Common Justifications for the Denial of a Health Insurance Claim

Wed Feb 7th, 2018 on     Health Insurance,    

Insurers — whether in the health insurance context, or some other context — will look for any possible justification to support their denial of a policyholder’s substantial claims, however legitimate those claims may be.  Recent scandals plaguing health insurers have shaken the industry to its core and revealed that many health insurers do not enforce their guidelines or properly supervise their assessors, which can lead to systemic wrongdoing. If you have a legitimate health insurance claim that has been denied by your insurer, you may be entitled to damages on the basis of their wrongful denial.  With the assistance of a qualified health insurance attorney, you can gather additional evidence and repackage your health insurance claim, appeal the denial, or — ultimately — pursue trial litigation against the insurer to recover the compensation to which you are entitled. Understanding the reasoning that insurers use to rationalize their claim denial is fundamentally important, as it highlights those issues that must be circumvented or challenged.  Consider the following. Common Justifications for Claim Denial Treatment Not Medically Necessary Whether treatment is deemed medically necessary depends on a number of factors, from the language and provisions of the insurance policy, to the circumstances of your injury (and potential treatment thereof).  Each plan may differ in terms of its definition of medically necessary treatment, with some plans executing a broader construction, and some plans executing a stricter construction.  For example, your plan may require that only certain type of medical devices be use to treat […]

Medically-Necessary Treatment and Health Insurance Denials

Fri Jan 19th, 2018 on     Health Insurance,    

In Florida — and in other jurisdictions throughout the country — many health insurance claims are denied on the basis of the insurer evaluating the treatment that their policyholder received as “medically unnecessary” or “medically inappropriate” given the circumstances of the injury or condition.  Despite the fact that most insurers view the claims filed by their policyholders as little more than a nuisance, the gritty reality is that a denial can be life-changing.  Denial of one’s legitimate health insurance claims can lead to significant financial stresses, and even bankruptcy. If you have been subjected to a wrongful denial of your health insurance claim, then it’s important that you get in contact with an experienced Florida health insurance attorney as soon as possible.  You have the right to appeal the denial of your claims, and — potentially — to sue and recover damages pursuant to litigation, if the denial was wrongful.  Contact Ver Ploeg & Lumpkin, P.A. to connect with a skilled health insurance attorney today. What is Medically Necessary? If your claim has been denied on the basis of it not being medically necessary, then you are likely wondering what constitutes “necessity” in the health insurance context.  There is no universal definition of medical necessity.  Generally speaking, each health insurance coverage plan defines “medically necessary” differently. For example, suppose that you suffer serious injuries in a motor vehicle accident and you have to get your leg partially re-constructed using metal scaffolding.  There are a variety of different brands, types, and […]

How a Pre-Existing Condition Affects Your Insurance Claim in an Accident

Wed Oct 18th, 2017 on     Health Insurance,    

Whether you are injured in an accident in which there is an at-fault third-party and are attempting to recover damages through the third-party’s liability insurance, or whether you’re making a first-party claim with your own health insurer, the presence of a pre-existing condition could complicate recovery somewhat. Injury Must Be Distinct or Aggravated In Florida, you may recover for injuries that are either distinct from a pre-existing injury, or that have simply aggravated a pre-existing injury to a substantial degree. Distinct Injury An injury may be new and distinct from a pre-existing injury, even if the new injury affects similar areas of the body — whether the injury is “distinct” may sometimes depend on how detailed the examination of the injury is. For example, suppose that you are suffering from a pre-existing shoulder injury.  You are later involved in an accident where your shoulder is further injured.  Though at first glance one might assume that the injuries are one and the same, medical imaging might reveal that the new injury caused damage to previously unaffected parts of the shoulder. Aggravated Injury Importantly, even if you have not suffered a distinct injury, you may be entitled to make an insurance claim if your pre-existing injury was aggravated in an accident.  Aggravation of a pre-existing injury may reduce your potential recovery, however, as you will only be entitled to the losses suffered as a result of the aggravation itself (not the injury as a whole). Let’s return to our shoulder injury example.  […]

Battling insurance companies for payment

Thu Feb 16th, 2017 on     Health Insurance,    

As a health care provider, you’re well aware of the daily struggle to get the payments you’re owed from the insurance company. It’s a miserable cycle: you provide the services for your patients, collect a minimal copayment and then get a notice saying it was denied. Now you’ve got bills to pay and you’re left with potentially hundreds of thousands of dollars in limbo because the insurance company delays payment or refuses to pay.

Insurers making health insurance denials based on bad faith

Fri Nov 25th, 2016 on     Health Insurance,    

Health insurers are not consumer-oriented protectors in our dog-eat-dog healthcare system of today. In fact, in Florida and elsewhere, some of the greatest heartache and family suffering has been caused by wrongful decisions of health insurers. It is common these days to receive a denial of health insurance coverage based on illogical and irrational reasons. These decisions are so hurtful to consumers that some of them must seek bankruptcy relief while others suffer permanent credit record blemishes for outlandish medical bills that they cannot pay.

Gift dilemma? Don’t know what to get someone who has everything?

Mon Nov 24th, 2014 on     Health Insurance,    

The holidays can be stressful for those of us who have hard-to-shop-for relatives. Books, neckties, kitchen gadgets, socks, movie tickets, fruit baskets and gift cards — it has all been done before, sometimes many times before. We came across something the other day that could be perfect for a certain sub-category of the hard-to-shop-fors: pet insurance.

Yes, men are gullible, but why won’t they ask for directions? p3

Sat Nov 1st, 2014 on     Health Insurance,    

We are close to finishing up our discussion of the survey conducted by . The researchers wanted to gauge how many Americans fell for some long-held beliefs about insurance coverage. Men, it turns out, were more susceptible to misinformation than women. Overall, though, the results showed that we are all becoming savvier consumers of insurance.

Why a medical claim may be denied

Mon Oct 13th, 2014 on     Health Insurance,    

No one plans to get sick or develop a medical condition, but the reality is that these things happen and, when they do, the costs associated with medical care and treatments are often astronomical. Health insurance exists to help defray costs associated with medical care. For example, if an individual gets sick and needs to go to the doctor, his or her health insurance typically covers a portion of the expenses related to a doctor’s visit or hospital medical tests.

Coverage under ACA may end abruptly for 94,000 Floridians

Sat Sep 6th, 2014 on     Health Insurance,    

It may look as if the federal government is a classic example of one hand not knowing what the other is doing, but 310,000 people now know or will soon know differently. It turns out that their Affordable Care Act applications or enrollment records do not agree with the records of the Citizenship and Immigration Services division of the U.S. Department of Homeland Security. The ACA only covers people who are in the country legally.

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