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How the Health Insurance Appeals Process Works in Florida

Fri Mar 30th, 2018 on     Health Insurance,    

In Florida, and elsewhere, health insurance policyholders are entitled to appeal adverse determinations by their insurer — such as a denial of coverage — and thereby request that the insurer conduct a full review of their original decision.

The appeals process is the first of several steps in challenging the determination made by your health insurer.  After you have exhausted the internal appeals process, you can move forward with an external, third-party review of the insurer’s decision, submit a complaint with a Florida state agency (such as the Florida Agency for Health Care Administration), or bring an action against your insurer (thus precipitating litigation).

Even if you’re not sure whether you’d like to file a lawsuit against the insurer and pursue litigation in the Florida courts, it’s worth consulting with an experienced Miami health insurance lawyer to help guide you through the appeals process.  Depending on the circumstances surrounding the denial of your health insurance claim, you may be able to persuade the insurer to accept your claim.

The Appeals Process in Florida

So, how does the appeals process work?

When you file a claim, you’re essentially requesting that your health insurer cover (and therefore reimburse) the costs of treatment.  If your insurer denies your claim, however, then that qualifies as an adverse determination, which you are entitled to challenge pursuant to the appeals process.

Every insurer tends to have somewhat different grievance and appeals procedures (though they all must comply with state and federal regulation).  For example, some Florida health insurers have an informal grievance process where you can meet with administrators without having to file a formal written appeal, and attempt to negotiate a satisfactory resolution to the dispute at-issue.

Generally speaking, however, all Florida health insurers must implement a formal grievance process through which you can give written notice of your appeal and thus challenge their adverse determination.  When you submit your appeal, you will have to include various documentation and information so that the insurer can properly identify the claims at-issue in your appeal.

Not all insurers require that you exhaust the internal appeals process before moving forward with external, third-party review.  Depending on the policy, it may be more sensible to begin with an external review of your claim denial.

Internal appeals must be processed within 60 days of submitting your appeal.  Of course, not all situations allow for that length of time to pass without a resolution.  Expedited review must always be available to policyholders who find themselves in emergency or otherwise urgent situations.  An urgent care review may be requested if the normal length of the appeals process would jeopardize your health in a significant way.  Urgent reviews may be completed within a few days of the request.

Schedule a Free Consultation With an Experienced Miami Health Insurance Lawyer

Here at Ver Ploeg & Lumpkin, we have over two decades of experience representing a range of policyholder-clients (individuals and businesses) in disputes with their insurers, including in disputes with health insurance companies.  We have grown substantially over the years, and now operate out of two offices — in Orlando and Miami — and field a team of more than 25 attorneys.  Still, despite our size, we remain committed to the principles that have enabled our success: detail-oriented service, thorough preparation for litigation, and personalized representation.

Our results speak for themselves.  We have secured multimillion dollar settlements and verdicts on behalf of our clients.  In the Florida health insurance context, we secured both a $6.1 million jury verdict and a $4 million recovery on behalf of our policyholder-clients.  We have been recognized by various publications, including US News and World Report, and Super Lawyers.

Call (305) 577-3996 today to get in touch with an experienced Miami health insurance lawyer here at Ver Ploeg & Lumpkin.

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