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Denied Claims Blog

Your Insurer’s Word Doesn’t Have to Be the Last

November 16, 2012

California residents can challenge an insurer’s denial for medical treatment, and the state wants to make sure you know that.

When Ethan Moeckel’s autism led to a struggle with behavioral issues in the classroom, his parents searched for the appropriate treatment. They eventually found intensive behavioral therapy, but at a cost of $500 to $600 a week, their insurer denied it and called the treatment medically unnecessary.

So the Moeckels turned to an Independent Medical Review, or IMR, an option available in California in which consumers can appeal an insurer’s decision to an independent board. A month after the couple submitted the appeal, the IMR ruled in their favor, and Ethan’s therapy was covered, giving him a pathway to thrive in a traditional classroom.

IMR: A Resource for Consumers

California’s Department of Managed Health Care is reaching out to the public in an effort to raise awareness about the IMR process. In 2011, the department overturned insurance rejections in 640 cases and insurers withdrew denials in another 294 cases before the IMR process went through. Before filing an IMR, you should file an appeal with their insurer. If that’s not successful, you can turn to the DMHC or the state’s Department of Insurance to file the IMR.

The IMR Process Explained

An IMR can be filed if:

  • Your insurance company denies, delays or calls treatment medically unnecessary
  • Denies coverage on the basis of treatment being experimental
  • Denies coverage for urgent or emergency services

The IMR process generally takes about 30 days.

Not Everyone Wins the Appeal

But sometimes, insurance companies can be tenacious in their denials. In states that don’t have the resources Californians enjoy, consumers can be left to tussle with the red tape put up by insurance companies at a time when they’re already suffering, either from their own medical illness or the stress of caring for a loved one. Battling a giant corporation on your own to get the benefits you were promised shouldn’t be added to the hardships of illness and stress. The Moeckels were lucky–they followed the IMR process and won. But in 2011, 690 insurer decisions were upheld by the IMR process. Those families will have to make difficult financial decisions to afford treatment they thought their insurers would cover.

An IMR is Not Your Last Resort

You don’t have to be one of those families. When insurance companies unfairly put profits over your health, our attorneys will fight to get you the benefits and compensation you deserve. And you won’t have to pay a penny until we do so. You purchased insurance for peace of mind. When insurers like Unum, Cigna or Standard unscrupulously take that from you, our team fights your battle so you can focus on what’s important: beating your illness or helping your loved one fight.

Contact Us

If your insurer has unscrupulously denied your benefits, contact us for a free consultation.

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