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Denied health insurance claims are a big problem.
Health insurance is fundamental to keeping you and your family well. When it is unfairly denied, it can cause panic, serious illness, and financial debt. We are here to help you get the medical care you need.
Denied health insurance claims usually fall into one of several categories:
The treatment was "not medically necessary."
The health plan often tries to claim that the doctor ordered the wrong treatment for the illness and, therefore, there is no coverage. These claims are usually fought by digging into the medical records and establishing whether the treating physicians appropriately utilized less expensive forms of treatment before resorting to more drastic means.
The prescribed treatment was "experimental in nature."
In essence, this is the insurance company saying that the recommended procedure is not supported by medical research. These are highly complex claims and are won and lost on the basis of the findings in medical journals.
The policy has an exclusion, which nullifies coverage.
Generally speaking, the insurance company has the burden of proof to show that an exclusion is valid. Moreover, there are laws that effectively overrule many exclusions, especially those that are unreasonable or defeat the essential purpose of the policy itself. Many times these denials can be successfully challenged.
The Premium was not paid on time.
This is a very common justification for a denial, but a careful examination of insurance company records can show that they were inaccurate or that the insurance company legally waived the late payment.
A pre-existing condition limited coverage.
While pre-existing conditions are less relevant in light of the Patient Protection and Affordable Care Act (ACA or "Obamacare"), they are still relevant to health care plans that are exempt from ACA. Typically, insurance companies save money by not examining insurance applications carefully. Generally, the insurance adjuster will then claim the policy should be rescinded. There are multiple ways to overcome this kind of denial including utilizing a careful examination of medical and other records to show that the insurance company had notice of medical issue.
The appeal process was not properly followed.
Filing appeal paperwork exactly according to legal standards and doing so by deadlines is extremely important. Failing to do this can give the insurance company a huge advantage in court. Accordingly, it is very important that you seek legal counsel if you are uncertain about how and when to appeal. Generally speaking, you must follow the insurance company’s internal appeals procedure before you have any right to pursue your legal rights. In many cases, the deadlines are a matter of days.
Acting promptly to preserve your rights is extremely important. Insurance companies work hard to prevent people from hiring their own attorney because they want to be the only one with lawyers on their side.
Who can you trust to deal with your insurance claim?
With +20 years of experience dealing with insurance claims, attorney L. Craig Nierman is well equipped to file and advocate for your claim. While this might be your first time dealing with a challenging insurance situation, Mr. Nierman has filed thousands of claims for his clients. His experience includes working at one of the nation’s largest insurance companies, training attorneys on best practices/techniques, and teaching Insurance Law at the University of Iowa. Even other attorneys retain him to strengthen their insurance cases as an expert witness, testifying in numerous state and federal courts. This experience gives you a significant advantage as we fight for you.
While our firm has a dynamic team of 12 attorneys, paralegals, and other support staff, Mr. Nierman remains directly involved in every case he accepts. With experience with claims involving personal injuries, life insurance, health insurance, homeowners insurance, workers compensation, disability, and wrongful death, we look forward to learning how we can help you move forward. Contact L. Craig Nierman today for a no fee consultation.