Facing a Claim Denial? How Public Employees Can Use External Review and When to Sue for Bad Faith
When you are a public employee who has had your insurance claim denied, your options range from working to have your claim covered to suing the insurance company directly, or even doing both. The Orange County insurance bad faith lawyers at Quincey Law can help you decide your path forward.
When your claim has been wrongfully denied by the insurance company, you not only want to have it covered, but you may also want to take action when the law has been broken. There are two separate yet related goals at work when your insurance claim as a public employee has been denied. A bad faith lawsuit can handle both of these aims, and you may be able to file it without external review and certainly afterward. You may even be able to sue for bad faith after you have won an external review case.
When the insurance company is taking a hard line with you, do it right back to them by hiring an attorney at Quincey Law. Our Orange County insurance bad faith attorneys can help you take back control when the insurance company tries to take it from you. Call us today at (866) 945-9175 to schedule a free initial consultation.
Should I Seek External Review of a Health Insurance Claim Denial?
The one thing that you may do when your claim has been denied is go through the insurance company’s internal review process. Although it seems like a waste of time to ask the same insurance company that denied your initial claim to reverse itself, it is a step that may help.
Assuming that the internal review merely rubber-stamps the initial determination, you are then left with the question of how to proceed next. In some cases, you may use external review through the Department of Managed Health Care (or, in some instances, the California Department of Insurance). These agencies will contract with an independent review organization that will consider medical evidence before making a decision about whether to order the insurance company to reverse the denial. External review can be an important tool, and it may not add much additional time to your case. These reviews are often conducted in 45 days or less.
You can decide that coverage of your claim is the most important thing to you, and you are willing to go to any measure to force the insurance company to pay it. An external review is often a helpful tool that is available to you, especially because decisions made are binding on the insurance company. However, external review does not allow you to seek bad faith damages because that is a matter for the courts, as opposed to the administrative system.
Do I Have to Go Through External Review Before I Sue the Insurance Company?
In some cases, you must go through an external review first before you can take the case to court. This is especially true when the dispute revolves around medical necessity, instead of contract interpretation. Then, you must exhaust all possible remedies, including external review, before you can file a direct lawsuit against the insurance company. Going through an external review can be helpful if you file a later case against the insurance company because it can build an even stronger record of possible bad faith.
There are circumstances in which you do not have to add the extra layer of going through external review. There is an important exception that may allow you to take your case straight to court and skip the external review process if that is what you decide is in your best interest. Specifically, if the insurance company has acted in bad faith, you can proceed directly to filing a lawsuit in court. If you are alleging that the insurance company has broken the law, as opposed to making an incorrect judgment call that is not necessarily illegal, you can begin your case with a lawsuit. For example, you may seek damages directly from the insurance company when they have committed any one of the following forms of illegal conduct:
- Unreasonable denial of valid claims, which includes completely ignoring the opinion of your treating physician or misapplying policy exclusions
- Using delay tactics, such as prolonging their review without any justification
- Overly relying on their own physicians who have never seen you and ignoring any contrary medical information
- Denying your claim without a clear reason
- Misrepresenting the terms of your policy
Wrongfully denying a health insurance claim is not necessarily a violation of the law in itself. However, when the process that was used to reach that result was unreasonable or illegal, then the insurance company can be made to face consequences.
Speak to an Orange County Insurance Bad Faith Law Firm
As a public employee, you have been promised health care as part of your job. Do not let the insurance company get away with wrongfully denying the care you are due. Schedule a free initial consultation with an Orange County insurance bad faith attorney at Quincey Law by visiting our website or by calling us today at (866) 945-9175.
Nicholas Quincey is the founder of Quincey Law, and has over a decade of experience of handling insurance claims denials and personal injury matters for people throughout California. We have pursued insurance bad faith claims for people involving life insurance, health insurance, homeowners and disability insurance. We also work with clients and families who need assistance filing and pursuing a personal injury matter. Learn more here.