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Chicago Health Insurance Lawyers
Helping clients throughout Chicago by demanding justice through insurance litigation
In light of skyrocketing health care costs, you pay your monthly health insurance premiums with the expectation of receiving some peace of mind in return. Many of us are keenly aware of the fact that we’d be unable to pay out of pocket for health care in the event of a catastrophic accident or significant health challenges. Some of us would even struggle to come up with the funds for more routine services.
You put your faith in your insurance company and – justifiably – expect them to hold up their end of the bargain. But what happens when they don’t? Health insurance disputes can be incredibly frustrating. It’s easy to feel small and helpless when facing down a powerful corporation with seemingly limitless resources.
At Gainsberg Injury and Accident Lawyers, we work to level the field for our clients when it comes to holding health insurers accountable when they subvert their responsibilities. Our Chicago health insurance lawyers are thoroughly familiar with health insurance contracts. We are skilled negotiators who are always up to the challenge of holding insurers’ feet to the fire on behalf of our clients.
Some of the health insurance companies that serve the Chicago area that our clients have worked with include:
- Allstate Insurance
- BlueCross BlueShield of Illinois
- Cigna health care – Illinois
- Humana Inc.
Whether your dispute is with one of the above insurers or with an entirely different company, we’d love to learn more about your case. Contact our team today for a free case review, and let’s discuss whether you may be within your rights to take action against an insurance company for wrongful claim denials.
Table of contents
- What is health insurance?
- Disputes with health insurance companies
- Why was my health insurance claim denied?
- What is a medical necessity dispute?
- What if treatment was preauthorized?
- Can I challenge an out-of-network denial?
- What is ERISA?
- How do I resolve a health insurance dispute?
- Chicago health insurance frequently asked questions
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What is health insurance?
Health insurance is a type of insurance policy that covers the medical expenses of the person who purchased the policy (and their dependents if it is a family plan). Depending on the type of plan, the insured is responsible for paying a monthly premium and making a co-payment for certain types of care. In return, policyholders get coverage for necessary health care expenses like office visits to a doctor, surgery, emergency room visits, and prescription medication costs.
Many plans require an insured person to meet a deductible before the plan begins paying for certain covered services. If your health insurance policy has a $2,500 deductible, you may need to pay $2,500 toward covered services subject to the deductible before your insurance begins paying its share.
Disputes with health insurance companies
Health care coverage disputes are far too common here in the United States. Our health care and insurance systems are seemingly always in flux, which can lead to confusion and disagreements about what should or should not be covered and by whom.
Some of the common factors in health insurance disputes include the following:
- Wrongfully denied claims for benefits
- Denial of coverage for hospitalization or a legitimate medical procedure
- Inaccurate charges for services
- Refusal to cover innovative treatment options
- Refusal to cover care for psychiatric conditions
When you seek medical care, you’re often already in a vulnerable state. When your health and wellness are on the line, insurance denial can be incredibly frustrating and downright scary. If you’re not able to pay for the treatment you need, your condition may worsen, or you may go into insurmountable debt.
We know how high the stakes are in these cases. That’s why our team is dedicated to supporting clients across Illinois in their efforts to hold insurance companies accountable for unjustifiable denials and other vexatious and unreasonable conduct.
Why was my health insurance claim denied?
Health insurance companies deny claims for all kinds of reasons. Some of these denials are legitimate. Others may be up for debate. In our practice, we commonly see health insurance claims denied for the following reasons:
Coverage exclusions
The fine print of the policy says a particular treatment or expense isn’t eligible for coverage.
Lack of preauthorization
Some insurance companies want to pre-approve certain treatments prior to agreeing to cover them. If your provider didn’t receive a prior authorization from the insurer, the insurance company may refuse to cover the service.
Medical necessity disputes
An insurer might claim that the service or medication in question isn’t actually medically necessary and therefore not eligible for coverage. Medical necessity can be subjective. Just because your doctor orders it doesn't mean the insurance company will cover it.
Out-of-network treatment
If you visited a doctor or facility that was out-of-network, any services you received may not be covered. Even at an in-network facility, out-of-network providers can create coverage disputes, although federal and Illinois law protect patients from many forms of surprise billing.
Missing documentation
Insurers might claim they lack necessary documentation like records of past treatments or other relevant data.
Billing or coding errors
If your procedure wasn’t coded properly, your claim may be denied even though it technically should have been approved. These kinds of errors are largely out of your control, which can be frustrating.
Administrative mistakes
Human error can trigger denials. These mistakes may happen on the insurer’s end or on the part of the medical provider.
If your claim is denied, you may be able to file an appeal. If you get to the end of the appeals process and your claim is still being denied, you may have to consider alternative options for resolving the dispute.
What is a medical necessity dispute?
This is one of the most common situations we see in health insurance cases. Insurance companies will claim that a procedure or medication isn’t medically necessary and subsequently refuse to cover it. Insurers may require prior authorization or dispute whether a treatment is medically necessary (although Illinois-regulated plans may not impose step-therapy requirements).
This can lead to disputes between physicians and insurers. Sometimes, doctors can advocate on their patients’ behalf to the insurance company. This may involve a provider sending additional documentation to the insurer or engaging in something called a peer-to-peer (P2P) review. In some cases, insurance companies will reconsider or rescind prior denials after reviewing all of the information available to them.
Sometimes, however, insurance companies will stand by their original denials and refuse to approve treatments that patients and their doctors believe are medically necessary.
What if treatment was preauthorized?
Many patients understandably assume that a preauthorized treatment will be covered by their insurance when all is said and done. For Illinois-regulated plans, an approved prior authorization generally must be honored if the claim is properly coded and timely submitted, subject to limited statutory exceptions. Even so, these situations can be remarkably frustrating for patients and their medical providers.
If your health insurance claim was denied after treatment was preauthorized, don’t assume you’ve hit a dead end. You and your denied health insurance claim attorney should carefully review the details of the preauthorization, as well as the reasoning provided for the denial. Depending on the facts of your case, you may be within your rights to push back against the denial and advocate for coverage consistent with your policy.
Can I challenge an out-of-network denial?
A lot of us think of in-network vs. out-of-network coverage as fairly black and white. If a provider is in-network, they should be covered. If they’re out-of-network, they probably won’t be.
In reality, there’s a lot more nuance involved. As we’ve discussed, there are many reasons why a claim for in-network services could be denied. Similarly, there are situations in which your insurance company may cover certain out-of-network services and procedures.
If your claim was denied because it was deemed out-of-network, it’s still worth doing some digging. You may be able to appeal the decision if your in-network options were unreasonably limited. You may also be able to appeal if you needed emergency treatment or the wait to see an in-network provider would have put you at risk of harm.
If you think an out-of-network claim was inappropriately denied or you believe the services you received weren’t out-of-network in the first place, it may be wise to consult with a health insurance claim lawyer who can help you sort things out.
What is ERISA?
Many employer-sponsored health insurance plans are governed by a federal law known as the Employee Retirement Income Security Act, or ERISA. These claims involve some unique challenges because they are subject to their own procedural requirements and deadlines.
If you’re involved in an ERISA dispute, you may want to consider partnering with a legal team that has experience working on these cases. At Gainsberg Injury and Accident Lawyers, we understand the complicating factors involved in many ERISA disputes, and we know what it takes to support clients in these cases.
From gathering critical documentation to advocating on your behalf and everything in between, we are prepared to fight for your rights under state and federal law. It can be helpful to get an attorney on board during your initial appeal, as the documentation you provide and claims you make during the appeal may become relevant in the event that you pursue litigation down the line.
How do I resolve a health insurance dispute?
If you have a health insurance claim denied or you’re in the early stages of some other kind of health insurance dispute, there are some steps you can take on your own. Look over your health care plan documents to familiarize yourself with the ins and outs of your policy. Many common questions can be answered this way.
If, after reading your health care plan policy documents, you still believe that a procedure or service should have been covered by insurance, you can reach out to your insurer’s customer service department to request a review of your case. At this point, you can also ask them to send you a notice of denial that details the reasons for their refusal to cover your treatment.
If an Illinois Department of Insurance-regulated plan continues to uphold the denial after your appeal, you can file a complaint with IDOI. Self-funded ERISA plans may be subject to different federal procedures. If you reach this point in the process, you may want to consider contacting an experienced health care insurance dispute attorney who can advocate for you throughout the rest of the process.
Chicago health insurance frequently asked questions
Why was my health insurance claim denied?
Your claim could have been denied for many different reasons. Most commonly, we see claims denied due to questions about medical necessity, preauthorization issues, billing errors, missing documentation, or fine-print exclusions. Your denial letter should provide you with more specifics about your denial.
How do I appeal a denied health insurance claim?
Each insurance company has its own appeals process, and the specific protocols you follow will likely depend on the actual reason for your denial. Contact your insurer’s customer service department to request a review of your case and get more information about the appeal process.
What deadlines apply to appeals?
Appeal deadlines vary depending on the insurance policy and the type of plan involved. If you miss a deadline, you may be limited in terms of your appeal options. You should review your policy documents carefully so you don’t inadvertently miss your window.
What if my insurer refuses to cover a procedure?
You may be able to challenge the decision through the insurer's appeal process. In some cases, additional legal action is required to hold insurers accountable for failing to cover procedures in accordance with their own policies.
Can I recover the costs I already paid?
If an insurance dispute is resolved in your favor, you may be able to pursue reimbursement for out-of-pocket costs that you should never have paid in the first place. It depends on the facts of your case and the language of your policy.
How long does the appeals process take?
Appeal timelines vary by the type of claim and plan, but applicable law establishes deadlines for filing and deciding many health-insurance appeals. These cases are extremely fact-dependent, and there are many different factors that could influence the progression of your appeal.
Can a lawyer help with a denied claim?
Experienced insurance dispute lawyers bring advanced knowledge to the table. Whether you're considering filing an appeal or are seriously weighing other legal options, you may want to at least schedule a consultation with an attorney.
What if my insurance company keeps delaying a decision?
Repeated delays may justify additional investigation into the insurer's handling of the claim. If the investigation reveals that your insurer is vexatiously and unreasonably delaying a decision on a covered claim, you may have legal options.
Can I sue my health insurance company?
There are some insurance dispute cases that must ultimately be resolved via litigation. Your resolution options will depend on a combination of policy details and legal statutes, so you should consult with a knowledgeable attorney before making any moves.
Schedule a consultation with an experienced Chicago health insurance lawyer today
Under Illinois law, insurers must comply with their contractual and statutory obligations. If an investigation reveals that your insurance company wrongfully denied a covered claim, you may have legal options available to help you hold it accountable.
With more than 20 years of experience serving clients in Chicago, Gainsberg Injury and Accident Lawyers knows how to fight for your interests and hold insurance companies accountable for failing to do right by their customers.
Call, text, or stop by our office at 77 W. Washington St., Suite 1215 to schedule a free case review today. We are standing by to answer your questions and help you make an informed decision about how to handle your insurance dispute.
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