When people think of insurance companies denying claims, the first thing that usually comes to mind is car accidents and auto insurance companies. But what many people do not realize is that, every year, many insurance claims that are denied are actually health insurance claims, placing individuals and families desperately in trouble when it comes to necessary medical treatments and coverage.
The Bennett Law Firm has been helping victim policyholders who are wrongfully denied their benefits by health insurance companies for years, serving our communities in Oklahoma City and surrounding areas. We know that an insurance company’s failure to provide coverage not only may constitute bad faith, but most importantly, it can have devastating repercussions on your health and emotional well-being. If you were denied coverage in bad faith, contact one of our experienced bad faith insurance attorneys at 405-272-0303 to schedule a free consultation.
Exploiting Loopholes
Every day, giant HMOs make life or death decisions when it comes to covering health services for clients who have been dutifully paying for their benefits each month in case something happens to their health. And yet, these companies often wrongfully deny benefits to their customers, exploiting loopholes that do not rightfully exist, or simply just making arbitrary decisions to save money and hoping that clients won’t take them to court for it.
One of the more common “excuses” used by health care companies to deny coverage is due to “pre-existing conditions.” This typically refers to a condition that the company claims you had before your coverage started; thus, your policy does not cover it. Another common excuse is that they do not cover “experimental treatments,” although many actual medical professionals would argue that many of these treatments for which coverage is denied are no longer considered “experimental” by the medical community itself.
Other excuses used typically include that:
- The medical provider is not within the network;
- The procedure is not necessary (for example, is for aesthetic reasons);
- The policyholder made a factual error or lied in original paperwork, amongst others.
Insurance Company Duties
The insurance company owes you certain duties when it comes to your rights as a policyholder. Insurers are held to a covenant of good faith and fair dealing, as implied by all insurance policies. For example, they must have the interest and welfare of the insured in mind in considering whether or not a settlement offer is in your best interest. They must promptly and fairly investigate any claims as part of their duty to engage in good faith and fair dealing. In addition, in Oklahoma and several other states, an insurer has a duty to tender the policy limits when damages would clearly exceed the available insurance coverage. In other words, they cannot, in bad faith, refuse to settle a covered claim.
In addition, many health plans and insurance policies are covered under the Employee Retirement Security Income Act, which sets forth guidelines regarding fair treatment and protection. Although “Retirement Security” is in its title, in fact, if employers establish health plans, it also regulates their operation. One of the most significant amendments to the law prohibits health plans from refusing to cover an employee’s pre-existing medical condition under certain circumstances. It also bars them from discriminating based on health status, genetic information, any disabilities, and other conditions.
Local Oklahoma Cases
One of the recent cases that was publicized here in Oklahoma involved Blue Cross and Blue Shield of Oklahoma refusing to cover cancer treatments for some clients; specifically, proton therapy for clients whose bodies could not withstand “traditional” cancer treatments, such as radiation (for example, younger children). Oklahomans had to file lawsuits because, even though their doctors insisted on the treatment and do not classify it as “experimental,” the companies refused to cover the treatments.
In Oklahoma, a bill was passed prohibiting health benefit plans from purposely holding certain treatments to a higher standard of clinical evidence in order to find that it was covered under clients’ benefits. In other words, if the patient’s doctor recommends a particular treatment, the health insurance company needs to cover it. Unfortunately, this doesn’t seem to have thwarted some companies’ efforts to continue to avoid paying for claims.
Reach Out to Us for Help
If your health insurance company has denied your claim, or otherwise acted in bad faith, such as delaying or underpaying payments on your health insurance claim, we are here to help. In addition to suing the company for breaching their contract (policy) with you, they can also be sued for additional damage, such as punitive damages for wrongful conduct. Contact us online or call today at 405-272-0303 for a free consultation and we can discuss your rights and options with you.