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Unique Health Insurance Coverage Issues

Fri Jan 31st, 2020 on     FAQs,    

Experienced Miami Health Insurance Lawyer  

In the healthcare context, the insured are often surprised by the denial of their claims, and perhaps not unreasonably — when signing up for coverage, prospective policyholders are often sold an “ideal” of comprehensive coverage.  In essence, they are made to feel safe and secure.  The truth is substantially more complicated.

Insurance companies will use any available justification to deny a claim.  This is particularly exacerbated in healthcare situations where the insured is seeking out alternative care, or even experimental care.

We can help you secure the benefits you’re owed.

Ver Ploeg & Marino, P.A. is a Miami-based insurance litigation firm with decades of experience representing the interests of policyholders, and in a variety of disputes — including those that center around healthcare claim denials.  We are a practical, detail-oriented firm that is relentless in securing a favorable result.  Over the years, we have obtained numerous multimillion dollar verdicts and settlements on behalf of clients.

Unlike many of our insurance litigation competitors, we have spent a significant amount of time in the courtroom, navigating the hostile battlefield that characterizes a traditional lawsuit.

As such, we have the reputation necessary to put pressure on insurance companies to resolve the dispute early (and in a manner that is satisfactory to our client).  Insurers understand that if they do not demonstrate good faith in attempting to resolve the dispute painlessly, then we have the willingness and ability to challenge them in the courtroom.

Ready to speak to a seasoned Miami health insurance lawyer at VPM?  Call us at 305-577-3996 or complete an intake form through our website to request a consultation today.

Our Miami Health Insurance Lawyer Answers Your Frequently Asked Questions  

Are alternative, homeopathic treatments covered by health insurance plans?

It depends from plan-to-plan.  Though alternative medicine (such as acupuncture and massage therapy) is becoming increasingly common and well-accepted in both the medical community at-large and the general public, many insurance plans are still quite strict in defining what is “medically necessary” treatment.

Most plans extend coverage only to treatment that is “medically necessary.”  Some comprehensive plans will carve out specific categories of alternative medicine that will be covered, but other plans may not, shifting the burden to policyholders to prove that the alternative treatment is medically necessary.

Proving medical necessity will generally require that you show that the treatment is sufficiently cheap, safe, reliable, and effective.  This can be quite difficult with alternative medicine, as there is often a dearth of medical literature on such treatments.  You may be able to establish reliability and effectiveness by showing that you are making real progress with alternative treatments.

We encourage those involved in such disputes to contact an experienced Miami health insurance lawyer as soon as possible for assistance.

Are experimental treatments covered by health insurance plans?

Experimental medical treatments not only depend on the concept of “medical necessity,” but also on sliding scale considerations related to overall costs, risk, and likelihood of successful treatment.

Oftentimes, an experimental treatment is explored as an alternative when traditional treatments are ineffective, and when the medical issue faced by the patient is sufficiently severe that an experimental treatment is desirable despite the risks and costs.

When evaluating whether an experimental treatment is medically necessary, you’ll have to consider the costs, risks, likelihood of success, and the severity of the underlying health condition.  For example, if you have a mangled leg with damaged nerves, it might cause you nonstop pain that interferes with your ability to live a normal life.

Perhaps an experimental treatment exists that could correct the pain by fixing the nerve stimulation issue.  This treatment is very costly and risky, however.  The insurer might therefore attempt to paint the treatment as “medically unnecessary” by arguing that your underlying condition is not that severe (i.e., by arguing that your pain isn’t as bad as you’re claiming) or by arguing that the likelihood of success is simply too low to justify the cost and risk.  To some degree, winning this argument requires that you persuasively show how damaging the condition is and how transformative such treatment could be.

What sort of medical devices are not covered by health insurance plans?

As discussed earlier, medical devices must generally be deemed “medically necessary” to be covered by a healthcare plan.  In many healthcare plans, however, particularly those that are less comprehensive (and cheaper to purchase), coverage is extended only to medical devices that are durable.

Whether a device is durable depends on the “durability” definition in the healthcare insurance plan, though it’s worth noting that some plans keep this definition ambiguous.  Generally speaking, a device will not be considered durable if it does not remain medically useful (after repeated use, perhaps even daily use) for a number of years.  Exceptions may apply for devices that are meant to be thrown away after a short period of time, such as a cast or some other cycled device.

Some aspects of my health insurance plan are written in an ambiguous manner.  How will they be interpreted? 

In Florida, fortunately, the law is rather protective of the rights of insured policyholders, in the healthcare context and otherwise.  Ambiguous language in a health insurance contract will be interpreted favorably towards the policyholder — not the insurance company.

How does this play out, exactly?

Suppose that your insurance plan does not cover medical devices that are “unsafe” to use under normal circumstances.  The question of safety and normal circumstances is rather ambiguous.  After all, one could argue that a health regulator’s safety rating might qualify as a reference point for safety, but one might also argue that some other, fact-based evaluation should be used.

Similarly, what is a “normal” use-case for one patient might not be a normal use-case for another.  When the terms are clearly ambiguous (i.e., there is no other language that reduces ambiguity and no other guidance beyond the contract), the court will interpret the terms in a way that leans towards the interpretation of the policyholder, to the degree that such interpretation is not unreasonable.

Speak to a Knowledgeable Miami Health Insurance Lawyer Today

If you have additional questions or you would like to speak with an attorney to discuss your specific situation, do not hesitate to contact our office at 305-577-3996.

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