Denied Claims Blog
December 16, 2016
Lee Barrows‘ husband was treated at a Connecticut hospital. He stayed there for 5 days before being transferred to nursing home care. Now, Lee Barrows is getting hit with a huge bill because Medicare refuses to pay the claim. Why? Because of one word: observation.
Her husband was never actually admitted to the hospital. Instead, he was classified under observation status, meaning he was technically an outpatient. There are different coverage rules for observation status and, because Medicare only covers nursing home care after a 72-hour inpatient hospital stay, they won’t cover the cost of that care at all. (more…)
December 16, 2016
The unjust denial of a claim can be a frustrating time for a family already suffering through an illness. But one family in Central Florida took their frustration to their local TV station.
Skip Stearn was diagnosed with stage IV lung cancer and was counting on a disability insurance policy he had paid into as his family’s only source of income. Then Mutual of Omaha denied his claim, arguing that his cancer could have been a pre-existing condition.
Fighting Claim Denial – and Winning
Stearn and his wife, Jill, tried to fight the denial on their own, sending test results and doctor reports proving the cancer was not pre-existing. But it was all to no avail. That’s when they realized their fight needed some back-up.
The Stearns, struggling to pay bills, called a local Orlando TV station to help with their battle. The station’s “Action 9” segment called Mutual of Omaha on behalf of the couple. A week later, the claim was approved, although the company declined to comment on the air regarding its sudden about-face.
The station spoke to an insurance attorney who said claim denials are extremely common because employer-backed disability policies are so difficult to appeal. (more…)
December 16, 2013
Brandon Schmidt is 19. He wants to see the world. Instead, the teen is fighting for his life against cystic fibrosis from his home in Paradise, Calif.
Diagnosed at 4 months old, Brandon has undergone therapies since the age of 15. His lungs have collapsed 8 times, and he relies on large oxygen tanks to breathe. To save his life and give him a chance at fulfilling his dreams, Brandon needs a double lung transplant, a local TV station reported.
Resistance from Hospitals and Insurance
As Brandon struggles to breathe, his family is fighting for the life-saving procedure. Hospitals are hesitant to perform the surgery due to the risk of complications. The family is trying to schedule a consultation with UC San Francisco in hopes that the medical center will agree to do the surgery.
There is, however, another problem. The surgery would cost more than $400,000, and the family’s insurance provider is refusing to cover it. Insurance companies have also denied claims to cover the consultations for the transplant. (more…)
August 23, 2013
When your insurance claim is denied, it doesn’t end there. You have the right to appeal that decision, and you can enlist the help of an attorney to help you get what you deserve if you choose to do so. That’s what we do.
Some might say that it is not worth putting up a fight, or they may feel that it is impossible to successfully take on a huge insurance company. But that is simply not true.
Here is a recent example that proves that it pays to not back down to your insurer.
Big Victory for Missouri Policy Holders
When Missouri residents feel they have been treated unfairly or shortchanged by their insurance company, they can file a complaint with the Department of Insurance. Similar departments can be found in other states.
A plurality of these complaints in Missouri – 31% of them — pertain to health insurance claims. The most common complaint is a denied claim, followed by processing delays and unsatisfactory offers.
Filing complaints with the state yielded $10.1 million in additional insurance payments for state residents in only the first six months of 2013. This is money these people were owed but not paid by their insurance company, which only gave in once the government became involved.
These people can certainly rest a bit happier knowing they made the right decision by not simply giving up when their insurance company said “no.” (more…)
June 6, 2013
They don’t call it the insurance business for nothing. And it is undeniably a business — a big business. The health insurance industry includes about 1,000 companies with a combined annual revenue of about $500 billion. In this business, it is very important to remember that the playing field is not even.
Who are the players in the game? Basically, there are non-profit insurance companies and for-profit insurance companies. How your claims are handled — and the ultimate goal in the game — may be quite different for each.
With billions of dollars of cash in play, claims denial becomes part of a massive shell game, especially for the insurer looking to make a profit. If the insurer initially denies a claim, it can keep its cash reserves for just a bit longer and continue to earn interest on that cash until they ultimately accept and pay the claim, usually a few months later.
The good news? If you continue to fight your insurance company to pay for a denied claim, there’s a chance they will do so in the end. The bad news? It costs you time and energy. (more…)
April 3, 2013
The autism community won a battle against Blue Cross Blue Shield of Michigan on March 30 when a federal court in Detroit held that the denial of claims for Applied Behavior Analysis therapy was illegal.
The ruling came as a huge relief to the parents of autistic children. Advanced Behavior Analysis (ABA) therapy is a widely used and medically accepted treatment for autism. The U.S. Surgeon General, the National Institutes of Health, the American Academy of Pediatrics and the Medicare and Medicaid programs all agree that the evidence has shown ABA therapy to be effective.
Blue Cross Blue Shield, however, insisted on classifying the therapy as “experimental” and refused coverage to children with autism, according to a press release from the law firm that successfully challenged the insurer. (more…)
February 19, 2013
In May 2011, an elite team of Navy SEALs stormed a compound in Pakistan and killed Osama bin Laden, the terrorist responsible for the deaths of thousands of innocent Americans. The dramatic moment brought to an end one of the most — if not THE most — extensive manhunts in U.S. history.
About a year later, the soldier who actually fired the shots that killed bin Laden left the Navy after 16 years of service to the nation. That same day, the military pulled health care coverage for the man, his wife and children. No insurance. No pension. A $25 million reward was offered for bin Laden that no one will ever collect, and the man who killed him received next to nothing from the government.
December 12, 2012
If you are unfortunate enough to have your insurance company deny a claim you submitted that should be covered under your policy, you’ll probably spend a lot of time on the phone pleading your case. There’s a good chance your pleading will fall on deaf ears.
Bad faith insurance actions are just that—actions taken in bad faith for illegitimate reasons to boost the insurer’s bottom line. It’s a systemic practice, and one that government officials previously accused Unum of incorporating into the company’s business model.
It’s hard to have your voice heard over the greed of enormous insurance companies. But there are ways you can speak out. One woman has taken to the internet in hopes of changing the way insurance companies operate.
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. (more…)
October 26, 2012
The insurance provider Cigna has done everything it can to deny providing necessary care to 11-year-old Eve Yancey for her rare autoimmune disease.
Eve Yancey has battled cryopyrin-associated periodic syndrome (CAPS) her entire life. The genetic anomaly causes her body to overproduce a protein and can result in brain swelling, hives, hearing loss, severe gastrointestinal pain and developmental delays. That is, unless she gets the proper medical treatment.
Eve’s illness means she spends birthdays in the hospital and needs a hearing aid and monthly injections that cost $20,000 each. And if it weren’t for her mother fighting insurance provider Cigna at every turn to approve the girl’s medical treatments, Eve might have already died. (more…)