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Denied & Complex Health Insurance Claims

Health Insurance Coverage in Seattle

The American healthcare system is notorious for its complexities and frustrations. It might come as no surprise to learn that healthcare insurance companies are also known for less-than-ideal interactions with policyholders and claimants. If you have a complex health insurance claim, or if your claim was denied or delayed for any reason, then get Kantor & Kantor, LLP in Seattle on your side. We can provide all the legal assistance you need to pursue your claim with as little stress as possible.

We can help you deal with the following health insurance companies:

  • United Healthcare
  • BlueCross/BlueShield
  • Cigna
  • Kaiser
  • MetLife
  • And more

Understanding Your Health Insurance Benefits

The first step in any health insurance claim is knowing what benefits are owed to you. Not everyone gets the same coverage through their health insurance policy, so the benefits that someone else gets might not be available to you. Our Seattle health insurance attorneys can help you review your benefits and the fine details in your policy. Using our insight, we can see if you have valid grounds for seeking legal action against the insurance company, such as through a lawsuit or an appeal.

Health insurance benefits typically include:

  • In-network healthcare at a reduced cost
  • Low deductibles for most treatments
  • No-cost or low-cost preventative care
  • Dental and vision coverage for some plans
Tell our Seattle health insurance attorneys about your case now. Call 818-886-2525.

Reasons Why Health Insurance Claims are Denied

It is not unlawful for a health insurance company to deny your claim, assuming that there is a valid reason for the denial. If your claim was denied, then you should review the letter of denial closely to find the exact reason for it.

Health insurance denials often happen due to:

  • Out-of-network treatments
  • Insurer deems the treatments “experimental,” “elective,” and “not medically necessary”
  • Treatments are not supported by the medical community
  • Clerical errors like missing a signature on a form or incorrect coding
  • Coverage specifically excludes the treatment
  • Claim was filed too late

Problems and the consequent need for legal intervention arise when an insurer denies a claim without a valid reason. Give us a copy of the denial letter, and we can inspect it for any discrepancies that might make the denial incorrect. If there was no reason given at all, then it could be unlawful insurance bad faith, which we can challenge through a lawsuit. Otherwise, the next step might be using an appeal to ask the insurer to review your claim again and reverse its decision.

Thanks to our extensive legal experience, we have a high success rate with getting denials reversed during an appeal. We can also see if the insurer will settle your claim with a lump-sum payment. This option can get you all the benefits you need upfront and ends the case sooner, which the insurer often appreciates.

Material Misrepresentation

Another reason why health insurance companies deny claims is for material misrepresentation. If you give any misinformation to the health insurance company while applying for benefits or filing a claim, then, technically, material misrepresentation has happened, even if you did not intend for it. For example, you might mark your hair down as blonde when it is brunette. This is material misrepresentation, but not in a significant way that should cause your claim to be denied.

Material misrepresentation significant enough to cause a claim denial includes:

  • Failing to disclose that you are a smoker
  • Not including preexisting health conditions
  • Hiding your medical history
  • Not reporting dangerous hobbies like high-contact sports

We can help you if your case was denied for material misrepresentation, but a trivial reason, like the hair color example. Health insurance companies should not be using material misrepresentation as a “free excuse” to deny any claim it does not want to pay.

Contact us online at any time to learn more about our legal services.

Health Insurance Claims FAQ

Preexisting conditions can affect your health insurance claim, but only under certain circumstances. U.S. Department of Health & Human Services (HHS) regulations do not allow insurance companies to refuse your coverage because of a preexisting health condition if you get that coverage through your employer. Privately purchased health insurance plans can make special considerations for preexisting conditions, though.

Health insurance companies usually have a minimal amount of time to deny or approve a claim. Usually, 30 days is the maximum amount. If your claim is denied, then the process to appeal it or pursue a settlement can take much longer. We do everything we can to avoid delays and expedite your case because we know you are depending on that coverage.

If your claim was denied, then the insurance company processed it, reviewed it for discrepancies, and denied it. If your claim was rejected, then the insurer did not even process it before turning it away. The outcome is effectively the same, and both can be met with further action from our attorneys.

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]