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Our Lawyers Fight Insurance Denials of Surgery

Has Your Insurance Denied a Surgical Procedure?

At Kantor & Kantor, our attorneys who handle denied surgery claims are adept in guiding clients through the frustrating and frightening maze of denied insurance coverage, particularly when it comes to essential surgeries. We understand the stress and fear you and your family feel when your claim for a vital surgical procedure is turned down. The emotional and financial toll this denial can have on you is not lost on us. That’s precisely why we are here: to help you. Our dedicated team of skilled attorneys are well-versed in tackling the challenges of denied coverage for necessary surgery.

Armed with deep knowledge of insurance law and a history of successful outcomes for our clients, we are committed to championing your rights. Your health and well-being remain our central concern, and we are fully prepared to stand beside you at every step of the way. We will put our full resources into fighting for the surgery coverage you rightfully deserve but your insurance company wrongfully denied.

Facing insurance denial for surgery? Count on us at Kantor & Kantor. We’ll tackle the legal battle so you can get the surgical procedure you need. Call us today at 818-886-2525.

Is Your Surgery Insurance Coverage Provided by Your Employer?

If your claim for surgery was denied, it may be that you have a legal battle with your private insurance company. However, if your health insurance is provided through your job, it is possible your coverage is governed by a unique set of federal laws known as ERISA. In this case, your insurance coverage is considered a “plan”. While we may use wording related to an insurance company and an insurance policy as we discuss denied coverage for a surgery, know that you may have a “plan” instead of a “policy” when you have health insurance through work.

When you have an employer-sponsored plan, ERISA, the federal Employee Retirement Income Security Act of 1974, will apply1. ERISA is a labor law that was passed initially to govern retirement benefits but was soon expanded to cover employer-sponsored health insurance. Its administration and enforcement fall under the U.S. Department of Labor. One of the key aspects of ERISA is the establishment of minimum standards for employer-sponsored health insurance, encompassing documentation, reporting, and fiduciary requirements. Not only are health insurance cases complex, but those involving ERISA laws call for specialized legal representation. When you work with Kantor & Kantor you can count on our team to have that depth of knowledge. Our successful experience in ERISA cases runs deep. We also have contributed to important Supreme Court cases related to ERISA.

Why Choose Kantor & Kantor for Your Surgery Claim Denial?

Our Winning Strategy Has Helped Thousands of Policyholders

Facing a necessary surgery can be overwhelming. The last thing you need is problems with paying for it. If your insurance claim for a surgical procedure you need is denied, it puts a roadblock in the path to necessary medical treatment your doctor recommends. This situation can leave you and your loved ones in a vulnerable and uncertain position. Hiring the right attorney to fight your surgery insurance denial is crucial.

Selecting the most skilled California surgery insurance denial lawyer is pivotal for you. You need to win your case — your health depends on it. Kantor & Kantor is a highly regarded law firm with expertise in insurance law. We have an exceptional reputation among our peers, have won countless cases for clients and know the tactics necessary to win cases when surgery claims are denied.

  • Experience and Success: With over two decades of legal experience and a demonstrated history of challenging unjust insurance claim denials, including those involving surgical procedures, our California surgery insurance denial lawyers possess a profound understanding of insurance law, including the complexities tied to surgical procedure claims. Learn about cases we’ve won for other clients.
  • Client-Centered Approach: At Kantor & Kantor, we don’t treat you like a case file number. Our empathetic attorneys recognize the challenges you face and the stress that a necessary surgery brings, for both you and your family. Our compassionate team will support you throughout the process of your legal case.
  • Tailored Attention: Recognizing that every case is unique, we adopt an individualized strategy for each client. We are well aware of the emotional and financial toll that insurance coverage denial for a needed surgery can impose on individuals and their families. We will listen attentively, assess the intricacies of your claim, and develop a tailored legal approach that aligns with your goals. Communication is a priority to us. We will ensure you’re informed and engaged from the beginning to the end of your case.
  • Unwavering in the Face of Litigation: Unlike some firms that shy away from court battles, we stand ready to fight. We approach every case as if it’s headed to trial, often winning success within the courtroom. Insurance companies may offer inadequate settlements if they believe you’re more likely to settle outside of court. However, when they face the expertise of Kantor & Kantor, they understand that a significant and powerful legal challenge regarding a surgical procedure coverage denial stands before them. Rather than risk the costs of a trial verdict, insurers are inclined to propose a fairer settlement when you’re represented by our team.
  • Reputable Advocacy: Our reputation for tirelessly fighting for client rights is well-earned. Consult a judge, speak with legal professionals, or seek advice from mediators about who to turn to for cases of insurance coverage denial. It’s likely they’ll point you to Kantor & Kantor. Our reputation for standing up to insurance companies is a testament to our commitment and effectiveness in protecting the best interests of our clients.
  • Impacting Bad Faith Laws: Our legal expertise has been sought by colleagues presenting cases at the U.S. Supreme Court, resulting in our filing amicus briefs to support the rights of patients whose claims are denied. We also had direct impact on California laws governing denial of claims, including claims for surgical procedures.

Have questions or concerns? Our surgery insurance denial lawyers are here to provide answers, address your worries, and expertly guide you through the entire process. You’ll find we do so with great care and compassion for this difficult time you face.

Why Do Insurance Companies Deny Claims for Surgeries?

Our Team Knows How to Counter Insurance Company Tactics

Because insurance companies are a business, their bottom line is their first concern. This means your medical care may not be as important to an insurer as their profits are. This focus can have tragic outcomes for those in need of a surgery that is central to their health and future. In California, policyholders who are denied claims for surgical procedures can turn to the state government for support. The California Department of Insurance or  Department of Managed Health Care may provide an independent medical review of your denial2.

While help from a California government agency can be useful, it may be slow and not fully thorough. Working with attorneys who know bad faith insurance laws inside and out is your best option. Furthermore, if your health coverage is provided by your employer, that health plan is governed by federal, not state, laws.

Insurance claim denials for surgical procedures are disheartening and often unexpected. Several factors contribute to these surgery claim denials, and understanding them is crucial for navigating the complex landscape of insurance coverage. Here are some common reasons why insurance companies might deny a claim for a surgical procedure:

  • Medical Necessity: Insurers will scrutinize in detail whether the proposed surgical procedure is medically necessary. If they decide the surgery is elective or is not sufficiently supported by medical evidence, they may deny coverage. Providing comprehensive documentation from medical professionals is vital to establish the necessity of the procedure, and our attorneys can review your case to help determine what will best support your claim.
  • Preauthorization and Precertification: Many insurance policies require preauthorization or precertification before undergoing surgery. Failure to obtain these approvals before the procedure can result in a denial. It’s essential to follow the preapproval process outlined in your policy.
  • Out-of-Network Providers: Insurance plans often have a network of preferred providers. If you choose an out-of-network surgeon or facility, the insurer might deny the claim or cover only a fraction of the costs. Verifying the network status of providers before the surgery is crucial to avoid surprises. Sometimes, in-network providers lack the specialization you need for your surgery. You or your provider may already have made this clear to your insurer. When this is the case, our attorneys can advocate for why your denial of coverage of your surgery with an out-of-network surgeon is in bad faith.
  • Lack of Coverage: Some policies exclude coverage for specific surgical procedures or have limitations on coverage for certain conditions. Review your policy carefully to ensure that the procedure you need is covered. Regardless of what’s in your policy, it is advisable to speak to our attorneys about your case. We may find a valid legal argument to fight the denial of your claim for coverage of your surgery.
  • Documentation Errors: Incomplete or inaccurate documentation can lead to claim denials. Ensuring that all medical records, test results, and doctor’s notes are accurate and up to date can help prevent this issue. Be sure to keep on top of all of your medical records and review each document carefully. If necessary, ask your provider for a copy of all your records related to your need for surgery. You can also turn to our attorneys to help you obtain the necessary records to make your legal claim.
  • Policy Exclusions: Certain surgical procedures may be explicitly excluded from coverage due to the nature of the policy. Familiarize yourself with policy exclusions to avoid surprises. It’s possible that some denials of surgery are validly made, if your policy is specific about what surgeries are excluded from coverage. If the exclusion language is vague, our team may be able to help you.
  • Coding Errors: Medical billing relies on specific codes to categorize procedures. Coding errors can lead to claim denials. Ensuring that the correct codes are used is crucial to prevent this issue. This is a situation in which the expertise of our team is essential. We understand the detailed workings of surgical claims and their denials and know how even a simple error can result in uncessary denial of a surgery that you clearly need for your health condition.
  • Appeals Process: Insurance companies sometimes deny claims hoping that policyholders won’t challenge the decision. It’s as simple as that: They understand that you may just give up the fight. To that, we have quick and clear guidance: Don’t give up. Instead, depend upon our attorneys to take up the battle. When you face a health issue that calls for surgery, your ability to take on an insurance company is compromised. It’s difficult enough when you are in good health. Appeals can be highly complex, and there is more at stake because your initial claim was already denied. Your appeal of that denial of surgery may be your last chance to succeed with your claim.  Our health insurance denial attorneys have broad experience helping clients who come to us at the appeals stage.

Navigating insurance claim denials for surgical procedures can be complex, but understanding these potential reasons can help you address them effectively. Even better is choosing to get skilled legal representation. When you turn to our medical law practice at Kantor & Kantor, you can count on exceptional representation and service. Working with our winning team may significantly increase your chances of a successful resolution.

Denials Are Too Common In Claims Reviews

One way insurance companies save money and protect profits is to speed up the process of claim reviews. Part of that speedy process is the expectation that a large number of claims should be denied, and with little actual review of the details in the claim. The rate of denials of all health insurance claims, including surgery denials, is astounding. One company denies 50% of its claims, and the majority lean toward denial rather than approval.

Why Do Insurance Companies Deny Surgery Claims?

Even though data on denied claims through Medicare and Medicaid may not apply to your case, that information reveals an unfortunate trend. It provides insight into denials for people who file claims for needed health treatment. According to the KFF study, which examined denied claims from 2021, there are a few core reasons provided for denial of claims, and these likely include denial of surgery claims, too3:

  • 14% of treatment or procedure denials were because they were excluded by the policy.
  • 8% of denials were because required preauthorization or a referral was not provided.
  • 2% of denials happened because the treatment was deemed not medically necessary.

But this data does not tell the full story. Even when transparency in data related to insurance denials is required, companies can hide behind a category for denial which is labeled “all other reasons.” This was used in 77% of cases.

While that data shows an overall trend among all health insurance companies, some are more egregious in their denials than others. The highest rate of a company’s denial of claims for care from in-network providers reached an astronomical 50%. Clearly, the focus on denying claims is central to the business practices of some insurance companies. It is also a trend in health insurance claims review overall.  Just as some work is automated in many industries, so is the process of claims review. Not only does paying claims cost insurers money, so does paying medical professionals to review them.

Yet, it is required that medical professionals of an equal specialization should review claims. That means that if you file a claim for coverage of a surgical procedure, a provider with surgery experience and knowledge should review your claim. When the process is automated, chances are good that is not happening. Denials are becoming the norm, and few policyholders understand this trend. However our surgery claim denial lawyers know this reality all too well. We are also well-positioned to mount a strong legal battle against unfair claim denials.

There are some egregious examples of insurance company practices that are being made public. Reporting by the Washington Post discovered an insurer which created a job position called “Denial Nurse.” If that isn’t surprising enough, the reporters also found many instances of shocking denials. One example was a young college student who had an extreme allergic reaction which required the life-saving treatment of epinephrine and steroids intravenously at an emergency room. The insurance company denied the claim for payment saying that the treatment was not medically necessary. Without it, the youth would have died4.

Why You Need Legal Expertise When You Face a Surgery Claim Denial

While you may believe that your surgery is clearly needed and can’t imagine why an insurance company would deny your claim, you may find you have a legal battle in an unfathomable situation. This comes at a time when you are already dealing with health difficulties.

Work with surgery denial attorneys at Kantor & Kantor and we will research your denied claim. Depend upon our experience with countless health insurance cases to identify any bad faith practices that resulted in an unjust denial of your surgery claim. We’ll fight hard on your behalf, and you can depend on our reliable tactics in our history of winning cases.

Don’t work with just any lawyer to fight the denial of your surgery claim. Be certain you have a highly experienced team of attorneys helping you. Kantor & Kantor have helped people with cases just like yours. Call us today for help at 818-886-2525.


1 Employee Retirement Income Security Act of 1974.

2  California Department of Managed Care. Independent Medical Review and Complaint Reports.

3  Pollitz, Karen, Justin Lo and Rayna Wallace.  “Claims Denials and Appeals in ACA Market Plans 2021.” February 9, 2023. KFF.

4  Rosenthal, Elizabeth. Denials of Health Insurance Claims Are Rising and Getting Weirder. Washington Post. May 17, 2023.

Attorney Glenn Kantor, California

Attorney Glenn R. Kantor

Glenn Kantor is a founding partner of Kantor & Kantor LLP. As a young attorney, Glenn saw the injustice of wrongful insurance denials and created a law firm to represent individuals seeking to obtain their rightful benefits. Glenn is committed to ensure that clients receive the benefits they are entitled to under their insurance policies or group health plans. [Attorney Bio]