When Insurance Companies Refuse To Pay Medical Claims

Scott Blumenshine

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An all too familiar scenario is an insurance company that fails to pay a legitimate medical claim for a customer. Americans pay a lot each month to afford the medical care they need. Out-of-control medical costs drive insurance companies to have an outright denial policy for every claim unless the customer fights tooth and nail.

Most people have experienced insurance companies’ outrageous behavior at least once in their lifetime. When an insurance company fails to pay your claim, it is not the end of the road. You have options to appeal the decision and must understand your rights to fight for the coverage you deserve.

What do I do if my insurance company fails to pay my claim?

Especially for larger claims, many insurance companies will have a “deny first” policy. This entails sending a letter to the customer informing them that their claim has been deemed “not medically necessary” for coverage under their plan. This happens despite their doctor’s orders. They will direct the customer to file an appeal, which includes gathering a significant amount of paperwork and writing a detailed declaration, including the details of the claim. There is typically a term of 60-90 days in which the appeal is reviewed and a decision is given.

First Appeal Denial

After the first appeal is denied, the insurance company hopes you will give up and pay the claim yourself. Many people lack the resources, time, or knowledge to continue the fight. After a denial, you should seek the assistance of an experienced medical claim attorney. Hiring an attorney who understands the insurance system and how to argue your case makes all the difference effectively.

Second Appeal Denial

Second, appeals may still be denied even with a legitimate claim. Under the Affordable Care Act, insurers must have an external review process. The parties choose the review panel, which must be part of an independent review organization with adequate training in medical procedures. Generally, the insurance company will be forced to pay legitimate claims at this point. This process is extremely time-consuming and expensive, and the insurance companies are betting on most customers not to follow through with the complex process.

What medical insurance companies are required to tell me about my denial?

When you pay for a medical insurance plan, you have the right to certain information about your claim and coverage. The Affordable Care Act aimed to help bring more transparency between customers and insurance companies. When you have a large claim, it is important that you clearly understand your rights to certain information. Insurers are required to tell you:

  • Why a claim for coverage has been denied
  • You have the right to appeal to the insurance company and how to do it
  • You have the right to independent review by a third-party

If you have already been through the appeal process and your medical claim has been denied, you must take action to assert your rights. Speaking to an experienced medical claim attorney is the first step in showing the insurance company that you aren’t backing down. Your lawyer will act as a legal advocate and must seek your best interests. An attorney also helps to explain the complex process and create a legal strategy based on their knowledge and experience in dealing with insurance companies. There are certain time limitations when it comes to the appeal process, so it is crucial that you act sooner rather than later. Otherwise, you risk not receiving adequate coverage on your claim.

We have all heard cases where an insurance company refused to pay a customer’s claim, especially with the massive amount of online information. Friends, siblings, parents, other family, and people we might only know online—you can think of someone who has had problems with an insurance company on a claim. So, what happens when an insurance company refuses to pay a claim? How do we monitor and hold these insurance companies accountable when they do not hold up their part of the contract?

Chicago Medical Claims Attorneys

If you need help with an insurance company that refuses to pay your legitimate medical claims, contact the attorneys at the Blumenshine Law Group at (312) 766-1000 or email [email protected].

Here is a great article that focuses on keeping insurance companies honest when it comes to paying claims that everyone should read:


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