Few situations are more alarming than having a health insurance claim denied. Unfortunately, it happens often: according to a Policygenius study, over 25% of respondents refrained from getting health treatment because they didn’t know if their insurance covered it. When care isn’t covered, medical bills can be so expensive that they are one of the top reasons for personal bankruptcy in Florida. Other consequences include damaged credit and the inability to get essential treatment.
What’s especially concerning is that many health insurance claims are unfairly denied. The insurer may be making an honest mistake, but in some cases, the denial may be calculated to protect the company’s bottom line. When you have a dispute over healthcare coverage or believe your claim has been unfairly denied, you need an experienced Florida health insurance denial attorney on your side.
My Insurance Case represents individuals in health insurance denials throughout Florida. We thoroughly understand your rights under state and federal law, with special emphasis on those covering wrongful claim denials and other acts of insurance bad faith.
Florida Health Insurance Claim Filing Procedures
Once you submit a claim for medical expenses, Florida law requires your health insurance provider to make a decision within 120 days of receipt. (If they don’t pay it in a timely manner, they must pay interest on the amount due.) While the claim is pending, the insurer may require you to have a physical examination as often as is reasonably necessary to assess your condition.
Why Do Health Insurance Claims Often Get Denied?
Denials occur when an insurance company refuses to pay a healthcare claim. Some of the most common reasons that claims are denied include:
- A paperwork error has occurred. For example, your healthcare provider may list your name as John Q. Smith while the insurer has you on file as John O. Smith. Once the mistake is cleared up, insurance companies are often willing to revisit the claim.
- Your claim or pre-authorization request is incomplete. Your healthcare provider may not have specified in enough detail why you need the treatment or procedure.
- The insurer believes the requested service is not medically necessary, even if the patient needs it. In that case, your healthcare provider should provide more information regarding the reason for the treatment.
- Your doctor prescribes an expensive medication and lower-cost alternatives exist. In this case, the insurer may not want to cover your prescription unless your doctor confirms that the less expensive medication won’t have the same benefit.
- You are not covered for the health service you are requesting. For example, many healthcare insurance policies don’t cover cosmetic surgery. Similarly, some policies cover treatments like chiropractic and naturopathic care while others don’t.
- Your health plan’s rules were not properly followed. For example, you need pre-authorization for a specific, non-emergency test, yet you have the test done without it. If you don’t follow the rules, your insurer may deny payment for that test, even if you really need it.
- Healthcare services were not administered by an in-network provider. Managed care systems are typically very structured and you can only seek treatment from doctors and facilities that are part of your plan’s provider network.
- You did not pay your premiums. If your policy is allowed to lapse, it won’t provide coverage when you need it.
These denials, although frustrating, often have some justification on the provider’s part. What’s concerning is that health insurance claims can be denied for no other reason than that the insurance company wants to protect its bottom line. When this happens, they try to delay, underpay, or outright deny a legitimate claim.
How Do Insurance Companies Manage to Deny, Delay, and Underpay?
Health insurance companies often look for loopholes in their policies to avoid or minimize payouts. As discussed above, they delay claims for reasons that range from legitimate (the procedure is purely cosmetic or your claim form was incomplete) to questionable (they claim you didn’t pay your premiums when you know you’re up to date).
Delays
As far as delays go, health insurers are well-known for coming up with excuses for not paying claims in a timely manner. They claim that they never received the proper documentation from you or they request more information at a rate that’s beyond reasonable. Other strategies may include:
- Changing your representative
- Stalling the investigation into your claim
- Requesting unnecessary documents or records
- Requesting information piece by piece instead of all at once
At a time when you desperately need the coverage you paid for, your insurance company may delay claim approval to the point where you simply give up.
Underpaying
If you’re experiencing financial difficulties after a necessary but expensive medical procedure, the claims adjuster may offer a lower-than-expected payout. If you’ve already struggled through the delay and/or deny stages, you may accept this underpayment to get the matter over with. The insurer knows that at this stage, any financial relief is better than none for you.
In some cases, an insurance company tries to avoid paying a legitimate claim by canceling or rescinding the policy, leaving you without coverage for your future medical expenses.
What Rights Do You Have When Your Claim is Unfairly Denied?
Under Florida law, the insurance company must provide you with the contested portion of your claim and the specific reasons why it was denied within 45 days after receiving it. If the issue is missing information and you supply it, thereby making the claim valid, the insurer must pay or deny the claim within 60 days.
In addition:
- If your claim was denied as medically unnecessary, you must be given an opportunity to appeal to the insurer’s physician who reached that conclusion. Their response to your appeal must be made within 15 business days.
- If the reason for the denial was misstatements in your application or treatment for a preexisting condition, your Florida health insurer may not legally deny coverage if two years has passed since the policy was issued. On a similar note, coverage may not be denied for treatments related to a preexisting condition once two years have passed since the effective date of coverage.
- If you develop HIV or AIDS, your health insurance provider is not permitted to drop their coverage or refuse to renew it.
If your insurer disregards any of these rules or deadlines, they may be acting in bad faith, and an experienced Florida health insurance denial attorney can help you seek compensation.
How Can My Insurance Case Help With My Denied Health Insurance Claim?
Denial of insurance claims is on the rise in the health insurance industry. What’s even more unacceptable is when there’s no legitimate basis for the denial. Even if you ask your insurer for an explanation, you never get it.
When you hire My Insurance Case, we will aggressively fight for your rights and refuse to back down from any insurance company, no matter how large or small. Your Florida health insurance denial attorney will examine all aspects of your claim denial and determine whether or not the insurer may be acting in bad faith.
Everyone on our team is thoroughly familiar with how insurance companies work: their policies, procedures, and how they may try to delay, deny, or underpay a claim. With our experience and professional connections, we can ensure that your case is handled as efficiently and effectively as possible. For more information about how we can help you with your denied medical claims issues, contact us for a consultation.
What Are The Types Of Damages You Can Recover In An Insurance Bad Faith Case?
If you win your bad faith claim in Florida, you can recover both contractual and extracontractual damages.
The contract damages represent the amount that you were wrongfully denied. In most cases, interest is included as well. Extracontractual damages cover the economic and noneconomic damages you incurred because your insurer failed to treat you fairly.
Examples of economic damages you may be awarded include:
- Your out-of-pocket costs for medical treatment due to a denied claim
- Your lost wages as a result of being unable to work
- Attorney fees associated with the insurance bad faith lawsuit
Your noneconomic damages may include:
- Pain and suffering that resulted from being denied medical treatment
- Emotional distress
If the insurance company’s actions were especially negligent or malicious, you may also be awarded punitive damages. Unlike contract and extracontractual damages, which are meant to you for any losses, punitive damages are awarded as a means to punish the defendant for excessive wrongdoing.
The expertise of an attorney is particularly important when it comes to insurance bad faith claims. Ultimately, insurance companies will act in their best interests, and they won’t be afraid to retain counsel and defend their actions. Our team of experienced Florida health insurance denial attorneys can provide you with the skilled representation needed to challenge the denial and get the compensation you are entitled to as a victim of bad faith.
Our Florida Health Insurance Denial Lawyers Are Here to Help
Insurance companies are contractually obligated to cover losses specified in your policy. If your health insurance claim has been unfairly delayed or denied, schedule a no-obligation case review with one of our Florida insurance lawyers.
My Insurance Case has represented clients in health insurance denial claims against the biggest insurance providers. We know how to review and interpret the language on your policy and use that information to represent your interests against an insurance company that refuses to pay a valid claim. While we prefer to negotiate an efficient resolution, our attorneys have the skills and experience to hold an insurer accountable in court. To learn more, contact us for your free initial consultation.
