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Miami Health Insurance Lawyer Though healthcare insurance denials are common, many policyholders are shocked when they are denied benefits for having received a medical device at the behest of their treating physician.  In truth, healthcare insurers are built to deny as many claims as they can reasonably justify.  They profit and thrive on the expectation that you will not challenge their decision and that they will “get away” with not having to pay out the benefits that you might be owed. We can help. If you’ve had your healthcare insurance claim denied on the basis that your medical device is not covered by your policy, or for any other reason, then you may be entitled to challenge their initial decision and secure benefits.  Contact Ver Ploeg & Marino, P.A. for further assistance with your dispute. Let’s take a brief look at the basis for such denials. Medical Necessity Generally speaking, health insurers deny benefits for medical devices on the basis of medical necessity, which is a rather broad concept.  Every insurance policy is different, of course, and the definition of “medical necessity” can vary considerably from plan-to-plan.  Most share certain commonalities, however. Determining whether a device is medically necessary requires a comprehensive evaluation of factors: whether the use of such device is clinically appropriate, whether it has been provided in accordance with generally accepted standards of practice, and whether it is no more costly than competing devices or therapies that could produce an equivalent result. For example, suppose that you […]

Health insurance policyholders who are suffering from catastrophic or even life-threatening injuries, illness, and other medical conditions may find that their insurance carrier is not necessarily amenable to extending coverage to experimental treatments.  Though the outcome of an experimental treatment may not be certain, and though there may be concerns about efficacy, safety, and long-term health, there are many patients who are left with no other recourse. If your insurer has denied coverage for an experimental treatment that could fundamentally better your quality of life, or even save your life altogether, then you may be entitled to challenge their denial and obtain the benefits you deserve. Let’s explore the basics of medical necessity and health insurance policies. Medical Necessity, Cost-Effectiveness, and Other Concerns Private health insurance plans vary quite a bit.  Most insurance carriers offer health insurance coverage which requires that the policyholder demonstrate the “medical necessity” of their treatment in order to recover benefits.  There may be various exclusions, conditions that automatically qualify for benefits, etc., but medical necessity is often the underlying concept through which all benefits determinations are filtered. There is often no clear agreement about the meaning of medical necessity, however.  Some insurers will argue that “medical necessity” must involve an evaluation of cost-effectiveness as well.  Others will focus on the “need” aspect but may disagree that experimental treatment to improve a patient’s overall quality of life is medically necessary. Experimental Treatments Involve “Sliding Scale” Considerations As a general rule, experimental treatments are not clearly and […]

Miami Health Insurance Lawyer More than ever, Floridians suffering from injuries and illness — whether chronic or acute in nature — are seeking out alternative medical treatments (i.e., homeopathic remedies, massage therapy, traditional medicine, etc.) to resolve their health problems in a way that they feel comfortable with.  This trend is unsurprising.  In recent years, many have expressed their anxieties about the ubiquity of heavy pharmaceutical and surgical treatment in situations that might be more gently resolved through the use of alternative medicine. If you’ve received alternative medical care — in conjunction with standard medical treatment or exclusive of such treatment — then you may find that your health insurer denies your claim for benefits on the basis that your care is not “covered” or otherwise fits an exclusion in the insurance policy. It’s important to understand that a denial of benefits does not signal the end of your insurance claim.  You are entitled to challenge the decision of your insurer, and in fact, depending on the wording of the policy, the denial may have been wrongful. Let’s take a closer look. Healthcare Insurance Coverage is Generally Limited to Medically Necessary Treatment Most healthcare insurance coverage extends only to “medically necessary” treatment.  Every plan defines “medically necessary” differently.  One plan may explicitly list out treatments that are medically necessary (given certain diagnoses), while others may give a more general definition that references functional impairment.  For example, an insurance plan may deem treatment as “medically necessary” if it is cheap, efficacious, […]

In 1974, the Employee Retirement Income Security Act (ERISA) was enacted, thus creating new standards governing private employee benefit plans — such as employer-sponsored disability, health, and welfare insurance, among other plans.  In Florida and elsewhere, ERISA does not require that employers purchase private insurance coverage for their employees, but it does impose a stricter set of rules on such plans so that employee-policyholders are protected from the potential abuses of plan administrators and others. If you are a private employee in Florida, and you are a participant in an employee-sponsored benefits plan, then in all likelihood your plan is ERISA-covered.  This not only ensures that your plan will be governed by federal law (i.e., ERISA regulation), as opposed to Florida law, but also subjects you to various advantages and disadvantages when it comes to litigating claims against the insurer. Consider the following. Fiduciary Duties Give Rise to Legal Action ERISA establishes a range of fiduciary duties and obligations, which gives policyholders new opportunities to sue and recover damages for fiduciary violations.  For example, suppose that you are a policyholder in an employer-sponsored welfare plan.  You later discover that the funds were mishandled by the fiduciaries (i.e., the plan administrator and their agents), and this will have a substantial impact on your later benefits.  You would be entitled under ERISA to sue the fiduciaries and secure damages as compensation for your various losses. Florida Bad Faith Law is Preempted Under state law, section 624.155 of the Florida Statutes establishes bad […]

In Florida, and elsewhere, health insurance policyholders are entitled to appeal adverse determinations by their insurer — such as a denial of coverage — and thereby request that the insurer conduct a full review of their original decision. The appeals process is the first of several steps in challenging the determination made by your health insurer.  After you have exhausted the internal appeals process, you can move forward with an external, third-party review of the insurer’s decision, submit a complaint with a Florida state agency (such as the Florida Agency for Health Care Administration), or bring an action against your insurer (thus precipitating litigation). Even if you’re not sure whether you’d like to file a lawsuit against the insurer and pursue litigation in the Florida courts, it’s worth consulting with an experienced Miami health insurance lawyer to help guide you through the appeals process.  Depending on the circumstances surrounding the denial of your health insurance claim, you may be able to persuade the insurer to accept your claim. The Appeals Process in Florida So, how does the appeals process work? When you file a claim, you’re essentially requesting that your health insurer cover (and therefore reimburse) the costs of treatment.  If your insurer denies your claim, however, then that qualifies as an adverse determination, which you are entitled to challenge pursuant to the appeals process. Every insurer tends to have somewhat different grievance and appeals procedures (though they all must comply with state and federal regulation).  For example, some Florida […]

Insurers — whether in the health insurance context, or some other context — will look for any possible justification to support their denial of a policyholder’s substantial claims, however legitimate those claims may be.  Recent scandals plaguing health insurers have shaken the industry to its core and revealed that many health insurers do not enforce their guidelines or properly supervise their assessors, which can lead to systemic wrongdoing. If you have a legitimate health insurance claim that has been denied by your insurer, you may be entitled to damages on the basis of their wrongful denial.  With the assistance of a qualified health insurance attorney, you can gather additional evidence and repackage your health insurance claim, appeal the denial, or — ultimately — pursue trial litigation against the insurer to recover the compensation to which you are entitled. Understanding the reasoning that insurers use to rationalize their claim denial is fundamentally important, as it highlights those issues that must be circumvented or challenged.  Consider the following. Common Justifications for Claim Denial Treatment Not Medically Necessary Whether treatment is deemed medically necessary depends on a number of factors, from the language and provisions of the insurance policy, to the circumstances of your injury (and potential treatment thereof).  Each plan may differ in terms of its definition of medically necessary treatment, with some plans executing a broader construction, and some plans executing a stricter construction.  For example, your plan may require that only certain type of medical devices be use to treat […]

In Florida — and in other jurisdictions throughout the country — many health insurance claims are denied on the basis of the insurer evaluating the treatment that their policyholder received as “medically unnecessary” or “medically inappropriate” given the circumstances of the injury or condition.  Despite the fact that most insurers view the claims filed by their policyholders as little more than a nuisance, the gritty reality is that a denial can be life-changing.  Denial of one’s legitimate health insurance claims can lead to significant financial stresses, and even bankruptcy. If you have been subjected to a wrongful denial of your health insurance claim, then it’s important that you get in contact with an experienced Florida health insurance attorney as soon as possible.  You have the right to appeal the denial of your claims, and — potentially — to sue and recover damages pursuant to litigation, if the denial was wrongful.  Contact Ver Ploeg & Marino, P.A. to connect with a skilled health insurance attorney today. What is Medically Necessary? If your claim has been denied on the basis of it not being medically necessary, then you are likely wondering what constitutes “necessity” in the health insurance context.  There is no universal definition of medical necessity.  Generally speaking, each health insurance coverage plan defines “medically necessary” differently. For example, suppose that you suffer serious injuries in a motor vehicle accident and you have to get your leg partially re-constructed using metal scaffolding.  There are a variety of different brands, types, and […]

Whether you are injured in an accident in which there is an at-fault third-party and are attempting to recover damages through the third-party’s liability insurance, or whether you’re making a first-party claim with your own health insurer, the presence of a pre-existing condition could complicate recovery somewhat. Injury Must Be Distinct or Aggravated In Florida, you may recover for injuries that are either distinct from a pre-existing injury, or that have simply aggravated a pre-existing injury to a substantial degree. Distinct Injury An injury may be new and distinct from a pre-existing injury, even if the new injury affects similar areas of the body — whether the injury is “distinct” may sometimes depend on how detailed the examination of the injury is. For example, suppose that you are suffering from a pre-existing shoulder injury.  You are later involved in an accident where your shoulder is further injured.  Though at first glance one might assume that the injuries are one and the same, medical imaging might reveal that the new injury caused damage to previously unaffected parts of the shoulder. Aggravated Injury Importantly, even if you have not suffered a distinct injury, you may be entitled to make an insurance claim if your pre-existing injury was aggravated in an accident.  Aggravation of a pre-existing injury may reduce your potential recovery, however, as you will only be entitled to the losses suffered as a result of the aggravation itself (not the injury as a whole). Let’s return to our shoulder injury example.  […]

As a health care provider, you’re well aware of the daily struggle to get the payments you’re owed from the insurance company. It’s a miserable cycle: you provide the services for your patients, collect a minimal copayment and then get a notice saying it was denied. Now you’ve got bills to pay and you’re left with potentially hundreds of thousands of dollars in limbo because the insurance company delays payment or refuses to pay.

Health insurers are not consumer-oriented protectors in our dog-eat-dog healthcare system of today. In fact, in Florida and elsewhere, some of the greatest heartache and family suffering has been caused by wrongful decisions of health insurers. It is common these days to receive a denial of health insurance coverage based on illogical and irrational reasons. These decisions are so hurtful to consumers that some of them must seek bankruptcy relief while others suffer permanent credit record blemishes for outlandish medical bills that they cannot pay.