The New York Times has an interesting article today on what an injury victim or patient should do when they believe an insurance claim for medical treatment has been wrongly denied. And while the article has some good recommendations it fails to capture the whole picture.
Let’s set the scene: let’s assume that you are involved in a personal injury accident in San Francisco – an automobile accident or car wreck, a trucking accident, maybe a fall – something of that nature. And you and your doctor decide that you need a certain procedure. So, your doctor schedules it but then you both are notified by your health insurance company that your claim for the procedure or treatment has been denied. Now what do you do?
According to the Times, one in fourteen claims just like the one I described above is denied. Now it’s true that often claims are denied for legitimate reasons – meaning the procedure or treatment is not medically necessary or is simply not covered in the insured’s policy. But what the Times article does not detail is that many insurance companies employ people to do nothing but comb over their policy holder’s past medical records looking for any reason at all to deny coverage.
We reported on one such example ending in a $37 million dollar jury verdict against the insurance company here on San Francisco Injury Law Answers recently (click here for the post).
The article encourages patients and injury victims to appeal the denial. And that is good advice. The Times article insinuates that many appeals are won and provides a quote from a health official in Kansas indicating that 53% of appeals in that state are won. What the article does not indicate is how many claims that are denied are appealed. My guess is not many and for good reasons; the appeals process is long, costly, takes an enormous amount of resources, and a certain amount of education and ability to understand the process and move the system forward. Insurance companies know this.
They know how hard appealing a denial is, they know how costly it can be, and they know that a certain percentage of folks simply will not be able to appeal even if they want to, which is one reason such a high number of claims are denied.
The article’s advice to policy holders including patients and injury victims is worth repeating:
1. Read your policy carefully.
2. Take your time and be careful before you act.
3. Do lots and lots of research.
4. Persist. In other words, go the distance and don’t give up if you are denied a second time.
5. Seek the help of a professional.
And I will add one more piece of advice that the Times does not include: if you feel that you have been wrongly denied a claim by your health insurance company and that the denial was done in bad faith – contact a personal injury attorney. Good luck.
