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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 formulations of this metal scaffolding, however.  In your insurance plan, there may be a definition of the product that explicitly constrains it to certain specifications.  If the product does not adhere to those specifications, then it will not fall within the “medically necessary” definition for the insurance plan.

As the determination of medical necessity can change significantly depending on the language of your insurance plan, and on the nature of your injury/illness/condition, it’s critical that you have your claims assessed by a qualified attorney early on.  Your attorney will conduct a full investigation into the facts (and will assess the insurance plan language) to determine whether your treatment comes within the ambit of medical necessity.

Process of Challenging a Denial

In the event that your claims have been denied on the basis of them not being medically necessary, Florida law provides you a statutory right to appeal to the physician who has reviewed the medical necessity of your claim under the plan.  The physician must respond within 15 business days.  The insurer must also provide you with specified reasons for denying your claim (within 45 days of notice of the claim).

If your appeal is denied, then you may pursue litigation against the insurer in order to secure damages.

If you have had your health insurance claim wrongfully denied, unreasonably delayed (in processing), undervalued by the insurer, or otherwise interfered with, then Florida law may entitle you to sue for damages.  Alternatively — with the assistance of a skilled health insurance lawyer — you may be able to revise and resubmit your insurance claim and thereby obtain an adequate payout.

Ver Ploeg & Lumpkin, P.A. is a Miami-based insurance litigation firm that has over two decades of experience representing policyholder clients in various disputes with their insurers.  We are committed to our clients, and provide aggressive, personalized legal advocacy throughout the litigation process.  As such, we are well-positioned to take your claims all the way through to trial, if necessary.

Call (305) 577-3996 to connect with an experienced Miami health insurance lawyer here at Ver Ploeg & Lumpkin, P.A.  During your free initial consultation, we will evaluation your insurance claims and help you determine the best path forward to secure compensation for your various losses.

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