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Insurance-Denied Prescription

Our Lawyers Fight Insurance Denial of Medication

When a doctor writes you a prescription, they intend that the medication will help treat your symptoms or illness. But sometimes you don’t get that important treatment because your insurer denies your claim. Some medications are necessary for you to perform simple tasks through your day; others are essential to fight illness; and some can be life saving.

When your insurance company doesn’t provide coverage for your medication, you are left worrying how you’ll either pay for it on your own or get by without it. This is not a choice you should have to make. If your insurance company should cover your medication, you deserve the best legal support possible to fight for that coverage.

Wondering how to fight insurance denial of your medication? Our attorneys at Kantor & Kantor know the tactics insurers use to deny medication claims. You need your medication. Call 818-886-2525 to get help today.

Insurance Denial of Medication Can Have Tragic Outcomes

For too many, the cost of medication is simply not affordable. If it weren’t for insurance, many Americans would not have the medications they need. If an insurance company denies coverage of a medication, people confront a difficult situation. When faced with the choice of spending a limited budget on food or medication, some may choose food.

The sad reality is that when medication coverage is denied, people do not receive the health care they deserve and need. People either go without, take less than the prescribed amount, or delay taking their medication. You may think one of these paths is your solution to a medication denial, but it doesn’t have to be. Talk to our attorneys to find out how we can help you.

Can an Insurance Company Refuse to Cover a Medication?

When you received your doctor’s prescription, you probably assumed you would have coverage and be able to get the medicine you need. When the prescription was denied, you may have been shocked and wonder, Can an insurance company refuse to cover a medication? Unfortunately, yes, it can. However, that doesn’t mean you shouldn’t fight for that coverage. It also doesn’t mean that refusal to cover your drug is lawful.

Insurance companies provide their insureds with drug formularies that list all medications for which they provide coverage. If your medication is not on this list, that doesn’t mean you can’t get it covered. However, you may have to fight to make it happen.

Take Action if Your Insurance Company Refuses to Cover Your Medication

California’s Department of Managed Health Care advises consumers to take action if an insurer won’t pay for a medication that a doctor prescribes. The first step is to have your doctor request approval from your insurance company. If the doctor’s request is denied, there are additional steps you can take on your own. However, if you reach out to  our attorneys for help, you’ll have our decades of legal experience with insurance denials working on your behalf.

Some insurers change their formularies and with little notice and will no longer cover a medication you’ve been taking that the company had paid for before. If this sudden change happened to you, there are options. Among them is an appeal of the decision, and during the appeals process your medication coverage should continue.

Turn to Our Experienced Medication Insurance Claim Denial Attorneys at Kantor & Kantor

Our attorneys know that your illness or symptoms can worsen without the needed medication. Time is of the essence to take legal action. We also understand the emotional and financial strain caused by having your medication denied by insurance. It can create such stress that your condition may get worse. When we take on your case, we’ll fight fiercely for you to get the benefits you paid for, need, and deserve.

We accept the full range of medication denial cases, including those involving ERISA claims. If your health insurance is provided by your employer, then ERISA applies.

Medication Claims Governed by ERISA

The Employee Retirement Income Security Act, or ERISA, is a federal law that was enacted in 1974 to protect employee benefits. At first, when the law was initially passed, it was intended to ensure that workers would receive their retirement pension benefits. Today, ERISA also covers health plans, disability plans, and other benefits. If your health plan is paid for by your employer, ERISA law applies to employer and plan coverage requirements as well as to any legal action you take.

Many law firms lack expertise in the complex, specialized area of ERISA law. When you work with our team at Kantor & Kantor, you can be sure you are represented by attorneys who have not only experience with ERISA cases, but also the detailed legal knowledge of how the law applies to your medication denial case.

Why Is My Health Coverage Called a “Plan” Instead of “Insurance”?

If you have coverage through your employer, it will likely be governed by ERISA, and that legislation uses the term “plan” rather than “insurance.”  Regardless of the term used, both apply to your getting the necessary coverage for medication you need.

Though we may use the term “insurance” here, as we discuss reasons for denied medication claims and strategies to fight those denials, if your employer has an ERISA plan, the battle to get your coverage will be similar — but the legal steps are not the same. Details matter when it comes to taking legal action to fight a medication denial. That’s why you need an attorney at Kantor & Kantor with extensive expertise in ERISA law so you can be certain you receive the best representation possible.

Why Choose Kantor & Kantor?

Our Winning Strategy Has Helped Thousands of Policyholders

When it comes down to it, you want representation in your medication denial case from attorneys that you know can win. Kantor & Kantor’s winning record in health-related claim denials is long. In our decades of experience, we’ve battled insurers in tough negotiations on behalf of our clients; we’ve helped clients win appeals; and we’ve taken cases to court.

Our record at trial is outstanding, and our reputation is built on that success. Fellow attorneys and even judges turn to us for help because they know our attorneys at Kantor & Kantor have an exceptional understanding of the law surrounding health insurance and ERISA cases.

We Are Always Current with Changes to the Law

Even with our detailed knowledge of the law, we stay on our toes. Our attorneys keep abreast not only of changes to the laws, but also of important cases impacting medication denials. With each court decision, we learn about how the courts interpret and apply these laws. Some attorneys claim they can handle prescription coverage cases but are unaware of recent cases and changes to the law.

We Treat You Like a Person Not a File Number

Too many of our clients have been treated poorly by their insurance company. When they have medical needs and are vulnerable, they are left in the lurch. Their requests for help or explanation may go unanswered and their appeals denied.

Our health insurance lawyers understand how to take action in bad faith legal cases, but we also recognize the difficult situation our clients face. You’ll find our team gives you the respect and compassion you deserve – especially when you’re fighting for medication coverage.

We Are Ready and Willing to Take Your Medication Denial Case to Trial

Many law firms prefer to settle cases in negotiation rather than go through the complicated process of a trial. However, once insurers learn which law firms take that approach, they know they can lowball a settlement offer. Kantor & Kantor is different. We are fierce litigators, unafraid to take even the largest of insurers to court. Our reputation precedes us when we negotiate cases, so you can rest assured that we will get the best possible outcome in negotiations. We are determined to get you justice and the full remedy you deserve in your medication denial case.

Learn How We’ve Helped Other Clients

Perhaps the best way to learn which attorneys to trust is to hear it from others like you. Find out why so many clients are glad they chose our dedicated team at Kantor & Kantor to represent them. We are proud of the many positive reviews of our satisfied clients.

Find out why we are the law firm that insurance companies fear and the attorneys that clients depend upon. Let us fight for you. Contact us today at 818-886-2525 to discuss the denial of your medication claim.

How Do I Fight Insurance Denial of Medication?

We Won’t Back Down in a Fight to Secure Coverage of Your Medication

If you or a loved one has taken any prescription medication, chances are good you know how expensive many of them can be. Those costs only seem to be increasing in recent years. Furthermore, the need for medications has also increased as more and more Americans face illness, injury and chronic conditions. The amount we spend on medications can be overwhelming to grasp. In 2022, the price tag for all prescriptions was $633.5 billion. The recent trend has been up in all respects. Not only was that total spending up 9.5% from 2021, but the use of medications grew by 5.9%. Based on this recent trend, researchers expect drug spending to increase another 6%-8% in 2023.

The astounding price tag of medications is carried by insurers and patients. Out of desperation and need, you may try to somehow find a way to pay for a medication, whether that means the cost of a high co-pay or the total cost of a medication your insurance company refuses to cover. Why would an insurance company deny payment for a medication? Often, the core reason is their bottom line. At the end of the day, an insurance company is a business, and it will seek to protect profits in every way possible.

How Our Medication Denial Lawyer Can Help You

Some health insurance companies routinely deny claims, including those for needed medications, in hopes that an insured won’t fight that decision. If you want to know how to fight insurance denial of medication, talk to one of our attorneys at Kantor & Kantor. You may be able to obtain coverage for your prescription with the help of your doctor, or you may need to take legal action. We will help you understand your options.

Our team is dedicated to helping those who have been treated unfairly by their health insurance company. Confronting a denial of your medication claim when you are fighting a medical condition is physically and mentally exhausting. Count on our attorneys to fight the insurance company’s denial of your medication. We’ll lift the burden of battle off your shoulders. When you trust us with your case we will:

  • Investigate why your medication was denied
  • Handle all communications with your insurer or plan administrator
  • Prepare and file documentation, including appeals of claim denials
  • Advise you about going to court if your medication claim continues to be denied
  • Represent you in settlement negotiations or at trial
  • Keep you closely informed throughout the entire process.

If you were unfairly denied insurance coverage of your medication, we will hold your insurer accountable.

We Are Unintimidated by Even the Largest Insurers

There are many companies that offer health insurance in California, and even more nationwide. Our team at Kantor & Kantor has fought legal cases and won against many, including some of the most well-known large companies:

  • Anthem
  • Blue Shield
  • HealthNet
  • Kaiser
  • United Healthcare.

If you receive notice that your medication is not covered by your insurance, don’t take that denial as the final word. Talk to our attorneys. We will provide you a free, 30-minute consultation in which you will learn whether you have grounds for a legal claim and get an understanding of the steps you’ll need to take to secure medication coverage.

We are people helping people. Call us for help today at 818-886-2525.

Why Would My Insurance Deny My Medication?

There are several reasons an insurer may use to deny coverage of a medication. They include:

Protecting Profit

Insurance companies are for-profit businesses and will seek to protect those profits in every decision they make regarding medications not listed in their formularies. Sometimes, that bottom line is what drives a decision to not cover a medication. However, there are other reasons, as well.

Not Medically Necessary

Insurers may deny coverage of a medication because the company decides the drug is not a necessity for treatment of your condition. Even if your doctor supplies information that shows your need for the medication, the company may deny the claim because the evidence was not strong enough to convince them. Our attorneys can help you by managing communications with your insurer. We will leverage our experience with similar medication denial cases to explain why you need the medication and why alternate treatments are not appropriate.

Change to Drug Formulary

Some insurers may decide that a particular medication should no longer be part of their formulary and, suddenly, a medication that had been covered no longer is. In California, if you find yourself in this situation, the law is on your side. Recent changes to the Health and Safety Code provide added protections for insureds. If you’ve already been taking a drug for a particular condition, an insurer cannot suddenly stop providing coverage for that medication. It must continue, even if the drug is removed from their formulary (HSC §1367.22). If you live outside California, the law may still work in your favor. Talk to our attorneys to find out.

FDA Approval Issues

Some insurers may refuse to cover a medication for a particular condition because they claim there is not FDA approval of that use. In this situation, our experienced attorneys can help you by showing the insurance company proof that the medication can, in fact, be used to treat your condition and that it has successfully done so in other cases. And, if you live in California, state law addresses exactly this situation to provide you legal protections from unfair medication denial (HSC § 1367.21).

ERISA and Denied Medications

Few policyholders understand what insurance laws apply to their insurance denial of medication coverage. Thankfully, if you work with our lawyers at Kantor & Kantor, you don’t have to. Once we learn the details of your situation, we will let you know whether federal or state laws govern the actions of your health insurance company. In short, ERISA law applies when your health insurance plan is provided through your employer.

Which Applies? ERISA or State Law?

Most of the time, only ERISA applies to cases involving employer-provided plans, but in some complex situations,  state laws may apply. There are some elements to ERISA law that are unique from typical bad faith cases governed by state laws. When state laws apply, the legal protections they offer vary from state to state. What if your employer is located in one state, such as Connecticut, but you work for the company out of an office located in California? Do Connecticut laws govern the actions of the insurer because they are located in that state? Do California laws apply because you, the employee, are located there? Or does only ERISA apply?

Appealing the Denial of Medication and ERISA

If the claims administrator at the insurance company denied your medication claim and you believe that denial was unjust, you may be tempted to take legal action right away. However, under ERISA, there is a step you must take first: filing an appeal. You cannot bring your fight to court without going through the appeals process. If your case does proceed to trial, there will be no jury. A federal court judge will make the decision about whether your health insurance company must pay for your medication.

When Your ERISA Case Goes to Court

If your medication denial proceeds to the next step, after an appeal, the complexity of ERISA law becomes even more challenging to understand. At this point, who gets to present evidence, how that evidence gets reviewed, and how the court comes to a decision is quite different than in a health insurance case governed by state law. Your legal battle over a denied medication claim may involve application of a range of complex laws. Only an attorney who understands which apply and when can skillfully argue your case.

FAQs About Insurance Denial of Medication Claims

If your medication has been denied by your insurer, you may not know what steps to take next. You may also have questions about how and why your medication was denied. While you will have some questions specific to the medication denial you face, there are some common questions our clients ask.

Can an Insurance Company Refuse to Cover a Medication?

Unfortunately, even though you need a medication to manage symptoms of a chronic condition or to fight an illness, your insurance company can refuse to cover your medication. If this happens, don’t give up. There is a good reason why your doctor prescribed your medication, and you and your doctor should make that clear to your insurance company. If you and your doctor have already contacted the company and failed to secure coverage, you can appeal the decision. Before you get too far in the fight to have your medication covered, get legal consultation so that you can understand whether your battle is worth it. There can be some unfortunate circumstances in which an insurance company can legally refuse to cover a medication.

What If My Insurance Should Cover My Medication and the Denial is an Error? 

When you face denial of medication coverage, it’s important to be persistent. Don’t take “no” for an answer right from the start. Every health insurer or ERISA plan administrator has a drug formulary that includes medications they will cover. However, the list is not exhaustive. There are medications specifically requested by doctors which should be covered. The formulary is a helpful starting point but should not be the end point.

If your insurance company denied your medication, your medical provider should contact the company, or plan administrator, to clarify why a medication outside the formulary is necessary. At that point, your medication coverage may be granted and you’ll know the initial denial was possibly in error.

If you are still denied, even after your doctor sends an explanation, you can appeal the medication denial. Perhaps at that stage an error will be discovered and your medication will be covered. Unfortunately, if you reach the appeal stage, you likely have a difficult path before you. If you haven’t sought help from an attorney, you should get assistance to ensure you have the best chance to win your appeal.

How Do I Write an Appeal for Medication Denial?

While there are certain details you should include in your appeal, and requirements for when and how you submit your appeal, it is best to have an attorney handle it on your behalf. If your insurance is provided by your employer and is governed by ERISA, the appeal stage is a requirement. Insurance companies will be familiar with appeals and rely upon their often-used tactics to deny them. Because strategy and knowledge of the law matters deeply at this point, reliance on a seasoned attorney may make or break your ability to secure coverage of your medication.

Do I Need a Lawyer if My Medication Was Denied by Insurance?

When you first receive a denial of coverage for your medication, you can turn to your doctor for help. It’s possible the denial can be easily rectified when your doctor writes your insurer and provides an explanation for your specific prescription. If the insurance company still refuses to cover your medication, you may need to seek legal help. The further you get into the process of fighting for coverage of your medication, the tougher it will be. It’s best to have an attorney on your side who has experience and expertise in medication denial cases.

If you have questions about the denial of your medication, we are ready to help. Our team offers a free, 30-minute consultation. We’ll explain how insurance laws apply to your case and what options you have to secure coverage of your medication.

What Happens if Drugs Are Not Covered by Insurance?

Turn to Our Attorneys for Help Today

If your drug is not covered by insurance, you can fight for your medical needs. Nobody should be denied their coverage of medication, whether they have a private insurance plan or are insured through an employer. Unfortunately, insurance companies find many reasons to deny medication claims, and sometimes they do so unfairly, at the expense of their policyholders. At Kantor & Kantor, we have more than two decades of experience helping people fight unjust treatment by insurance companies. Talk to our medication denial lawyer today about your case. To arrange a free consultation, call 818-886-2525. 

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]