We have experience handling health insurance claims. It’s common for someone having surgery to face a big dispute about how much the health insurer is going to pay. People always assume they are within their coverage, but there is language that says there is a possibility the insurer won’t cover an event or procedure.
Even if they get prior authorization for the medical procedure or treatment, it doesn’t mean the treatment is covered by the contract. In fact, it’s always recommended that you check your coverage first and not rely solely on the fact that the insurer authorized the treatment.
Other times, the health insurance company might claim the insured missed paying the insurance premiums and then claim the covered procedure or visitation was not covered.
Another common issue occurs when an insured seek treatment in an emergency visit. Most insurance companies would pay around 80%, depending on the plan. However, the insurance company may dispute whether it was for genuine emergency care, which would affect how much they would be obligated to pay under the policy.
Q: Can an insurance lawyer help me if there were no in-network providers?
An attorney can walk you through it but the key with these types of issues, before and after, is creating a good paper trail. All communication with the insurance company should be in writing. If there is a phone conversation with the insurance company, the insured should take the time to confirm what transpired in the phone conversation with a letter or email to the insurance company.
Q: What kind of exclusions do you see in health insurance policies?
That depends on the kind of policy the person bought. There is considerable litigation that occurs wherein a person may have purchased a policy to save money, but it doesn’t meet the needs of the purchaser of the coverage. It’s a matter of reviewing the policy and the agreement closely.