Las Vegas Health Insurance Dispute Lawyer

Health insurance has long been an important topic of discussion here in the United States. Why? It has to do with ever-increasing medical costs in our country that individuals just cannot afford without the financial support health insurance provides.

Data from the American Bankruptcy Institute suggests that at least 62% of an estimated 2 million annual personal bankruptcies stem from a filer’s accumulation of health care expenses. Many residents of Las Vegas and other parts of Nevada secure jobs that offer employer-sponsored health insurance plans or secure government plans, or buy their own in the exchange (also known as the Affordable Care Act Marketplace) because they don’t want to have to worry about becoming encumbered by debt if they suffer a health setback.

What happens, though, when the health insurance coverage a person counts on being there for them if they get hurt in an accident, get sick and require surgery, need to spend time in the hospital, or something else, isn’t there for them?

Unfortunately, we see a lot of this at the Law Office of Matthew L. Sharp. Continue reading to learn more about these situations and the steps we generally recommend for someone who has been denied coverage for necessary medical care. In these situations, it may be worth speaking to a Las Vegas health insurance dispute lawyer.

Summary of Health Insurance

Unfortunately, the health insurance industry is in a state of calculated chaos where the industry acts as if it is above the law.

Your health insurance company owes you a duty of good faith and fair dealing to consider your interest at least equal to its interests. Your health insurance company must comply with Nevada laws and regulations called the Nevada Unfair Claims Practices Act. Your health insurance company has a responsibility to disclose the insurance coverage that are available and to interpret your insurance policy broadly to find coverage. Your health insurance company must investigate and evaluate your claim to look for reasons to pay the claim. Your health insurance company cannot deny a claim unless it has a good faith basis to do so.

But health insurance company rarely follow the rules of good faith and fair dealing. What should you be prepared for:

  1. You should identify the type of claim you have

There are two general types of claims. First, prior authorization claim is a request by your doctor to deem your procedure to be medically necessary under the terms of your insurance contract. Second, a claim for medical treatment that has already been provided. This is called a claim for indemnity.

  1. Your prior authorization claim is denied.

If your prior authorization claim is denied, your insurance company should tell you (not just your doctor) why the claim is denied. A letter should be provided by you to set forth the basis for the denial. In Nevada, a doctor of the same type of specialty as your doctor has to deny the claim. That means if a general practitioner or nurse practitioner denies a claim for surgery the denial is improper.

  1. Your claim for indemnity is denied.

You should make sure you have your explanation benefit. It should contain some information to explain why the claim was denied.

  1. When either a claim for prior authorization is denied or your claim for indemnity is denied, you should make sure you have your insurance policy.

You can usually get your insurance off the insurance company’s website.

  1. Ask the question: how do I get my insurance?

If you get your insurance through your employer, you will likely be required to file an appeal. It is important for legal reasons that you consult with an attorney before any appeal is filed. If you have individual insurance policy or if your employer is a public entity or a church, you should consult with an attorney about whether an appeal is required.

Typically, the insurance company used the appeal process as rigged process, but you may be required to go through the appeal to preserve a legal claim.

Why Health Insurance Denials Occur

Medical insurers deny medical insurance claims for a number of different reasons, with the following being the most popular ones:

  • The claim wasn’t submitted by timely filing deadlines
  • Treatment was received from an out-of-network provider
  • An insurer doesn’t cover certain medical procedures that a patient underwent
  • There were some inaccuracies contained on the claim form, such as a patient’s date of birth or gender (or it was altogether left off)
  • They determine that a treatment or procedure is not medically necessary
  • A medical procedure was deemed to be experimental in nature
  • The patient or their medical provider didn’t receive pre-authorization before performing a procedure

What Options Do You Have When Your Medical Insurance Denies Your Claim?

If you’ve received a letter from your health insurance company denying your claim citing one of the above-referenced reasons for doing so and have tried to refute the denial with no success, reach out to the Law Office of Matthew L. Sharp to discuss what your next steps should be with our experienced Las Vegas health insurance dispute lawyer.

In some situations filing an appeal demanding a re-review of your claim by the insurer may be warranted. Know that, if that doesn’t get resolved in your favor, most insurers’ policies’ terms and conditions describe how you must exhaust the appeals process when disputes arise before ultimately taking further action, like filing a bad faith insurance lawsuit, if applicable to your claim.

When you’re dealing with uncooperative insurers, remember that they have the upper hand. While not investigating your claim is a bad faith insurance practice, their reviewers are generally paid on a per-case basis, meaning they move quickly through them. It’s easy to see where they might deny a valid claim, and the unfortunate news is that you often get one or very few shots to have your claim reassessed. You may have an option of getting an independent review organization (IRO), also known as an external review of your claim, but once they render a decision, you may have run out of all possible options you can plausibly pursue on your own.

This is when a Las Vegas health insurance dispute lawyer can be of significant assistance to you. We know the sneaky tactics insurers engage in to avoid paying. When our firm, the Law Office of Matthew L. Sharp steps in, they know we understand what they do and won’t put up with it and, thus, tend to want to settle more quickly. So, if you have a health insurance issue that has long gone unresolved, call or email us to schedule a consultation to discuss your case and the options you can pursue in it.