What Happens If Your Health Insurance Denies Coverage for Surgery After an Accident in Rancho Cucamonga?
When the insurance company denies the care that you need after you have been injured in an accident, you can counter their denial with a lawsuit. The health insurance claim denial attorneys at Quincey Law can fight on your behalf.
Your health insurance company does not always cover the medical services that they are obligated to under the terms of your contract. Not only can you appeal the denial of your coverage, but you may also potentially sue the insurance company directly. If the insurance company has broken the law, they may be liable to you for bad faith damages.
Schedule a free initial consultation with the health insurance claim denial lawyers at Quincey Law. We can review your case and let you know if you can sue the insurance company.
California Insurance Companies Deny Many Claims
Even though California has generally pro-patient laws, the state still has a high rate of claim denial. Roughly one out of every five in-network claims is denied in California, and the denial rate for out-of-network claims is far higher. The problem is so bad in the state that laws were recently passed to prohibit denial of claims based on the use of artificial intelligence and to require insurance companies to publish their denial rates.
Insurance companies deny claims for various reasons, including:
- The procedure is not medically necessary
- The procedure is experimental and unproven
- The service is not covered by the terms of your policy
- You did not comply with the procedures specified by your policy
If there is a surgical procedure involved, there is likely a high dollar value attached. How you proceed after a claim denial could determine both whether the insurance company is forced to cover the procedure and possibly owe you damages. One of the first steps that you may take after your claim has been denied is to contact a health insurance claims denial attorney to discuss your case. They can advise you of the process that you must follow and how to enforce your legal rights under your policy. The insurance company may immediately take notice when you have hired an experienced attorney because they could fear potential consequences.
If you purchase your own insurance coverage, it is a contract between you and the insurance company, and it is generally governed by the laws of California. If you have health insurance through your employer, a federal law called ERISA likely which would govern your action against the health insurance company. Regardless of which law controls your case, you always have the right to appeal the denial.
You Must Appeal to the Insurance Company
If you are proceeding under state law, you may first go through the insurance company’s internal appeals process. You need to prepare quickly because you have a very limited amount of time to file your internal appeal. Unfortunately, these internal appeals are rarely successful, forcing you to proceed further through the process. You can then proceed through the California Department of Insurance or Department of Managed Health Care. If you are still not successful, you may have the right to file a lawsuit against the insurance company.
The primary purpose of your health insurance claim denial lawsuit is to force the insurance company to pay for the medical procedure. A court has the authority to order the insurance company to grant your claim. Your case would rely on complex medical evidence that may show that your procedure is medically necessary.
When You Can Sue the Insurance Company for Bad Faith
California law imposes certain obligations on health insurance companies when they are considering and responding to claims, including the obligation to act in good faith. If the insurance company breaches these obligations, you may be able to file a lawsuit directly against them to seek damages. If you can prove bad faith, you may be entitled to compensation beyond merely forcing the insurance company to cover the procedure that they denied. You could be entitled to be paid both for the financial losses that you have suffered and the emotional distress you have endured. You may even be able to receive punitive damages when the insurance company engaged in egregiously wrongful actions. To be clear, not every claim denial is the result of bad faith. However, you could receive compensation if the insurance company violated the law in denying your claim.
Contact an Inland Empire Health Insurance Claims Denial Law Firm Today
If your health insurance company has wrongfully denied your coverage, speak to the experienced health insurance claims denial attorneys at Quincey Law. You can schedule a free initial consultation with a health insurance claims denial attorney 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.