Reno Health Insurance Dispute Lawyer

Health insurance is supposed to provide financial and emotional protection in the event that a person becomes ill. Additionally, health insurance is purchased in order to help cover the costs of routine medical treatment and care. Unfortunately, many people face numerous roadblocks when pursuing health insurance coverage, especially when it comes to catastrophic injuries or costly medical treatment.

For more than 15 years, Reno health insurance attorney Matthew L. Sharp has successfully represented clients in lawsuits against health insurance companies. He fights to get his clients the health insurance coverage that they paid for and are entitled to receive.

If you are involved in a health insurance dispute, contact Reno health insurance attorney Matthew Sharp at (775) 324-1500 to learn more about your legal rights and options.

Health Insurance Coverage and Benefits

Reno health insurance dispute lawyer

There are generally two types of health insurance: (1) individual health insurance, which the policyholder purchases on his or her own behalf; and (2) group health insurance, which is purchased by an employer and provided as part of an employee benefits package. An insurance company’s obligations – as well as policyholders’ rights and options in connection with health insurance disputes – vary depending on whether the health insurance is provided through an individual policy or a group policy.

Under an individual health insurance policy, the insurance company must:

  • Promptly pay all valid claims
  • Investigate and evaluate all claims before denying or refuse to pay a claim
  • Provide a valid reason for a claim denial, including a factual and legal justification for the claim denial.

If an insurance company denies a health insurance claim without a valid legal or factual justification, the policyholder may have a claim for insurance bad faith. Group insurance policies are governed by the federal Employee Retirement Income Securities Act (ERISA). Under ERISA laws, appealing a denial of health insurance benefits can be a difficult and time-consuming process. Accordingly, it is highly recommended that you consult with an attorney as soon as possible for help with the appeals process.

Summary of Health Insurance

There are two general types of health insurance claims. First, a 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.

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 Reno and in all areas of 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.

If 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. 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.

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 an individual insurance policy or your employer is a public entity or a church, you should consult with an attorney about whether an appeal is required.

You should consult with a lawyer whenever your claim is being delayed or denied. You should know that your rights for legal reasons may vary significantly dependent upon whether you get your insurance through a private employer, a public employer, or purchased individually.

Insurance Bad Faith and Other Health Insurance Disputes

Health insurance companies, like all insurance companies, owe their customers a duty of good faith and fair dealing. If the health insurance company wrongfully denies benefits or otherwise violates the duty of good faith and fair dealing, it can be liable for insurance bad faith.

While there are many reputable health insurance companies, some favor their own interests to the detriment of their policyholders. When an insurance company acts in bad faith and fails to comply with their duty of good faith and fair dealing, the policyholders may be entitled to financial compensation for the damages caused by the bad faith conduct.

Some examples of areas where we see insurers denying coverage include the following:

  • Denial of medical treatment, especially in cases of longer treatment courses or those deemed more experimental such as cancer treatment plans like proton therapy or long-term pain management
  • Denial of treatment for degenerative conditions
  • Denial of hospital stays, long-term care, rehabilitative care, in-home nursing care, assisted living care, or adult daycare
  • Denial of medical equipment that can be used at home and is necessary for continued care
  • Denial of additional testing that can help diagnose a medical issue
  • Denial of medication, especially medication that’s newer on the market
  • Denial of necessary surgery, especially surgical procedures that are newer and more costly

Unfortunately, time and time again, we see that insurance companies make the decision to deny coverage to save their company money. An insurance company earns profit when you have insurance but don’t use it or use it fully. In situations like this where necessary care or treatment is denied, thankfully the law is on your side. Your health comes first.

Contact a Health Insurance Attorney

For more than 30 years, Matthew Sharp has successfully represented clients involved in health insurance disputes, including claims of bad faith, delay or underpayment of claims, and negligent referrals. Although he handles insurance disputes in variety of contexts, including auto insurance disputes and disability claim denials, he has a particular focus on handling insurance disputes in the health insurance and managed care context.

If you are involved in a health insurance dispute, do not delay. Contact Reno health insurance attorney Matthew Sharp at (775) 324-1500 today to learn more about getting the health insurance benefits to which you are entitled.