When you take out a health insurance plan with Covered California, it’s natural to expect that your plan will protect you when you’ve been injured or need medical care. However, this health insurance company don’t always pay out even when your claim is legitimate, which can leave you with a crippling burden of health care bills. Here at Stop Insurance Denial Law Firm, we help people all over the country stand up to health insurance companies and demand the coverage that they’re owed. But what are the reasons why Covered California might unjustly deny you coverage, and how can this denial affect you and your family?

What Is Health Insurance Denial?

A health insurance denial is whenever a health insurance company denies your claim to coverage for a health care expense. In some cases, a health insurance denial may be warranted; for instance, if you have a basic health insurance plan that covers emergencies and routine health care visits and you try to make a claim for your cosmetic surgery expenses, your health insurance provider will be within their rights to deny your claim.

If, however, your Covered California health insurance plan explicitly provides coverage for a health care expense that you’ve incurred but your insurance provider decides not to provide you coverage, you’ve been a victim of unjust health insurance denial. While health insurance companies often act in bad faith and deny their customers the coverage that they were promised, you aren’t powerless in the face of unjust health insurance denial.

Practiced attorneys have ways of exposing to a judge that a health insurance company isn’t holding up their end of a bargain. In some cases, health insurance denial can be caused by a simple understanding that can be cleared up without going to court, but if push comes to shove, having a qualified attorney by your side is essential if you want to make sure that you get the coverage that you’re owed.

Why Is Health Insurance Denied?

There are a number of reasons why Covered California might deny your claim. Before you jump to conclusions and assume that your insurance company is wrongfully denying you coverage, it’s important to become familiar with the various legitimate reasons why a health insurance denial can occur.

• Paperwork issues: Applying to have a medical procedure covered by insurance is a complicated process. Not only do you need to provide a significant amount of information to your insurance company, but your provider also needs to submit a great deal of paperwork to make sure that you get the coverage you need.

In some instances, you might make a mistake on your insurance paperwork that causes your insurance provider to deny your claim. This isn’t an instance of your provider acting in bad faith, and it can usually be resolved with a simple phone call or by resubmitting your coverage request.

It’s also important to keep in mind that while medical providers are held to a standard of professionality, mistakes can still be made in hospitals and doctor’s offices, which means that your provider may have made a paperwork error resulting in a denial of coverage. In this instance, you’ll need to work things out with your provider instead of pursuing litigation against your insurer.

• Timeliness issues: Most insurance providers require that providers submit coverage requests in a timely manner after a procedure has been performed. Even if there are no typographical errors in the coverage request document, if your provider fails to submit the relevant documentation promptly, you could be denied coverage.

Perhaps your provider temporarily lost your paperwork, or perhaps it was accidentally destroyed. Whatever the case may be, if your provider fails to submit your insurance paperwork quickly enough to have your procedure covered, you’ll need to take the issue up with your provider.

• Pre-approval was required: Depending on the nature of your insurance plan, some procedures may require prior authorization to be covered. Certain specialty drugs and procedures, such as MRI and CAT scans, may not be inherently covered by your insurance policy, and you may need to ask for coverage before you move forward with the procedure if you want to be covered.

Even if you apply for prior authorization, don’t simply expect that your procedure will be approved. Carefully study your provider’s guidelines for approving procedures, and make sure that you provide a full and clear approval request. If you fail to identify which procedures require prior authorization and take appropriate action, you’ll have no one to blame but yourself if your procedure isn’t covered.

• The procedure isn’t covered: Not all types of procedures are covered by your insurance. Some insurance plans cover more procedures than others, but other plans are relatively bare bones. Even if a procedure is needed to save your life, there’s no guarantee that your insurance plan will cover it, so it’s important to be fully acquainted with the specifics of your policy before you assume that your provider acted in bad faith.
• An out-of-network provider was used: To make sure that your procedure is covered by your insurance, you must make sure that you use a medical care provider that is within your insurance provider’s network. A network is a group of providers that all accept the same insurance, and if you work with a provider that isn’t within your network, you may lose the coverability of your procedure due to no fault of your insurance company.
• The procedure was not medically necessary: Most insurance companies do not provide coverage for procedures that are deemed as not medically necessary. For instance, almost every type of cosmetic insurance is considered to be medically unnecessary whether it’s liposuction, a facelift, or breast augmentation.

In addition, investigational procedures usually aren’t covered by medical insurance. These types of treatments are also called experimental procedures, and they are medical practices that may have merit but are not yet accepted by the medical community at large. In some cases, experimental procedures or drugs may have the ability to save your life, but it’s highly unlikely that your insurance plan will cover them.

Acting in Bad Faith

If you’ve ruled out all of the above situations as reasons why your insurance company may have denied you coverage, it’s possible that Covered California may have acted in bad faith. Since the Middle Ages, when two people or entities enter into a contract together, this choice is considered an act of faith, and it’s well-established that both parties must abide by the stipulations of the contract to avoid nullifying it.

In the case of an insurance policy contract, you provide the insurance company with the promise that you will pay the agreed-upon price for their services and that you will not exploit the system with fraud. In return, your insurance company agrees to provide you with the degree and type of health insurance coverage that are stipulated in your contract.

If you’ve held up your end of the contract but your insurer has failed to perform their duties, a court may find that they have acted in bad faith. While we’d all like to believe that insurance companies are paragons of virtue, it’s important to remember that insurers are for-profit companies that value the bottom line above everything else. In the search for maximum profit, insurance companies have been known to exploit their customers when they think that they can get away with it.

There are many examples of insurance companies being caught for bad faith practices. For instance, in the case of Boicourt v. Amex Assurance Co., it was determined in court that an insurance company failed to disclose permanent policy limits when a young boy was injured in a serious vehicle accident. The boy’s family was awarded a settlement of over $2 million to make up for this injustice.

In another case, Clayton v. United Services Automobile Association, a California court awarded the claimant $3.9 million because it was determined that the insurance company’s policy limits were unreasonable and in bad faith. Many similar cases have also resulted in awards to claimants who were wronged by unfair or unclear insurance policies.

Examples of Bad Faith Coverage Refusals

Insurance providers are masters of fine print, and they have developed a number of methods for denying medical coverage when it is rightfully deserved. Here are some examples of ways that insurance companies bend the rules or outright lie to get their way:

• Claiming that coverage isn’t provided: When all else fails, your insurance company might try bluffing. Even if it’s explicitly stated in your coverage documentation that your procedure or medication is covered, your insurance provider might lie and try to get away with it. Thankfully, it’s usually pretty easy to catch insurance companies in the act when they take this approach, and most judges would rule that such a move was taken in bad faith.
• Arguing that treatment isn’t necessary: Your insurance provider might also try to argue that your treatment was cosmetic or otherwise unnecessary. If it can be determined that your procedure was, in fact, necessary, it will be determined that your provider acted in bad faith.
• Determining that you have pre-existing conditions: Pre-existing conditions are a hot button issue and rightfully so. Some insurance companies may refuse to provide you with coverage based on other conditions that you had at the time of treatment. What’s worse, your insurer might examine your medical history after you file your claim to search for evidence that can be used against you.
• Mischaracterizing a treatment as experimental: Some treatments are legitimately experimental; as a general rule of thumb, if a procedure hasn’t been approved by the FDA, it is most likely experimental, and your insurance policy won’t cover it. However, most doctors within your insurance provider’s network also won’t perform experimental procedures, which means that if your procedure was performed in a major hospital, it probably wasn’t experimental.

Sometimes, insurance providers will try to hide behind the experimental treatment excuse as a way to avoid paying out on your policy. There are ways, however, for the court to determine whether or not your procedure was truly experimental, and the results can be disastrous for your insurance company if the court rules in your favor.

• Delaying the claim process unreasonably: Instead of outright denying your claim, your insurer may choose to delay the claim process until you give up. Unfortunately, most insurance companies aren’t explicitly forced to process claims within a certain period of time, which means that you’ll need to catch your insurer in the act of wrongfully delaying your claim process if you want justice.
• Fabrication or refusal of evidence: To judge whether or not your claim is valid, your insurance company will perform a detailed investigation regarding the procedure or treatment. As part of this investigation, your insurance company will gather as much evidence as possible, and they will weigh all of the available evidence to determine whether or not your claim is valid.

However, your insurance company or even Covered California may not do things by the book when they perform your claim investigation. If they think that they can get away with it, for instance, your insurance company may refuse to consider evidence proving that your claim was valid. They may also make up fake evidence in an attempt to discount the validity of your claim. Thankfully, it’s usually relatively easy to catch an insurer in the act of fabricating evidence or denying real evidence, but you’ll need a competent lawyer by your side to make sure that you get the justice you deserve.

• Investigation obstruction: To make it harder for you to make your claim, your insurance provider may obstruct their own investigation of the evidence behind your claim. It’s true that competent investigations can take a long time to complete, but if your insurer is dragging your insurance claim on for an unreasonable amount of time, you may be able to prove that they acted in bad faith.
• Unreasonably focusing on technicalities: Insurance providers such as Covered California are masters of the fine print, and they often have fail-safes built into their policies that will protect them in case of a dispute. For instance, if you didn’t file paperwork in the exact way that they demand, your insurance policy may hold up coverage on the basis of a technicality. If it’s found that your insurance company is withholding coverage based on adherence to minor bureaucratic requirements, most courts would rule in your favor.

Your Health Insurance Can Be Rescinded

In a worst case scenario, Covered California may decide to rescind your coverage entirely when you file your claim. Your insurer has the option to either pay your claim, deny your claim, or rescind your policy when your claim is filed, and if they decide that the benefits outweigh the risks, they will rescind your policy outright. This action would suddenly leave you without health care coverage, and if it can be determined that your insurer acted in bad faith when they rescinded your coverage, you will be owed a substantial settlement.

What Can You Do When You’ve Been Denied Coverage?

When Covered California has denied you coverage for a rightful insurance claim, it’s natural to be indignant. Unfortunately, many people stop there and never transform their frustration into the justice they deserve for their maltreatment. If you feel that you have been wrongfully denied insurance coverage, it’s important to begin the process of overcoming your situation by taking action.

The first step you’ll need to take is to carefully consider whether or not you’ve truly been denied coverage unfairly. Insurance policies are complicated, and it can sometimes be hard to tell whether you or your insurance company made a mistake in the handling of your claim. A competent lawyer can help you sort out all of the fine print and determine who is at fault in the case of your insurance claim.

If you and your legal team are able to determine that you have, in fact, been denied coverage unfairly, then you’ll be able to file a lawsuit against your insurance company on the basis that they breached your contract in bad faith. While there’s no guarantee that you’ll be able to win this lawsuit, taking this approach gives you the opportunity to seek the justice that you deserve. The best way to defend your interests in court is to work with qualified lawyers who are familiar with the tricks that insurance companies use to wrongfully deny coverage.

Speak with a Covered California Insurance Denial Expert Near Me

If Covered California has denied your rightful claim, there’s no reason to stand idly by and accept the situation. By law, your insurance company is bound to hold up its end of the deal, and you can take legal action to make sure that your health care costs are covered in full. Wherever you’re located in the United States, you can get the help you need by calling Stop Insurance Denial Law Firm at 310-878-1771 today.