Houston Health Insurance Claims Lawyer

Health insurance is an extremely useful and often lifesaving resource for many people. Those in need of medical or mental health care get the help they need at little to no cost to them. That is, of course, unless their insurance provider wrongfully denied their coverage. It sounds strange, but the fact is that health insurance companies do deny claims for illegitimate reasons. That’s why many people turn to a health insurance claims lawyer for guidance on where to go from there. At Reich & Binstock, we know that sometimes, insurance companies flat-out deny valid claims. On top of the frustration that comes with a denial, the appeals process is even more confusing. Without an experienced health insurance claims lawyer, the way ahead seems daunting. That’s why we’re here to offer those experiencing claims denial the help they need. If you filed a claim that was denied and need help in the appeals process, don’t hesitate to reach out. Call Reich & Binstock today for your free consultation at 713-622-7271.

What Type of Lawyer Covers Health Insurance Claims?

A health insurance claims lawyer in Houston is well-equipped to handle all manner of cases involving legal actions against health insurance companies. At Reich & Binstock, we have a wealth of resources to help you in any case against major insurance companies. We seek justice for those with wrongfully denied or underpaid claims.

When looking for a health insurance claims lawyer, you want to select counsel that can communicate effectively about your case through every single step of the process. This not only gives your case a better chance, but also boosts your confidence in the case as a whole.

Below, we list the actions your attorney will take to help your case move forward:

  • Review your claim externally
  • Determine whether there were bad faith insurance practices
  • Estimate how much your case/claim is actually worth
  • Consult both medical and legal experts to support your case
  • Communicate with your insurance company on your behalf
  • Gather evidence in support of your claim
  • Fight for your right to just compensation in the form of medical bill reimbursement and other damages
  • Take your case to trial if the insurer refuses to settle fairly

How Do Health Insurance Claims Work?

Health insurance claims are basically bills that your doctor sends to your health insurance provider for services rendered. Generally, plans involve a low-cost copay for things like routine checkups and visits, while your insurance company covers the rest of the visit.

Before you even visit the doctor, your insurance policy will state what you do and do not receive coverage for. When you choose a policy, it is imperative to read through it and contact your insurance representative to explain anything you don’t understand.

Once you cover the copay, your doctor bills your insurance provider for the remaining amount. The claims processing center of the insurance company receives the bill, then compares the explanation of benefits to the bill.

If the insurance policy covers what the bill lists, then they pay your doctor. If the policy does not cover those services, you must cover the remaining balance. At first, this seems simple. But what about denied claims? This is where the process usually gets tricky.

If the company denies coverage for you, you’ll likely receive a huge bill that you simply can’t afford.

The first step is to give the company a call and ask about the denial. Sometimes, administrative error is to blame. If they give you a reason for the denial, it is possible to request a review. Resubmit the claim. If you receive another denial, contact your health insurance claims lawyer right away.

How Long Do Health Insurance Claims Take?

This varies depending on a number of important factors. The three most important factors are your insurer, your state, and the type of claim you submit. Most states have consumer protections in place by requiring insurance companies to handle their claims quickly. Many states, including Texas, have specific time periods during which the insurers must acknowledge and investigate a claim.

In Texas, insurers must acknowledge that they received a claim within 15 days of receiving the claim. Then, after receiving all the necessary paperwork, they have 15 days to either accept or deny your claim. Finally, the company has 45 days to decide whether to pay or deny your claim, and they must inform you in writing of their decision. If they decide to pay, they must do so within 5 days.

Why Do Health Insurance Companies Deny Claims?

Sometimes, simple mistakes result in valid claims being denied. Other times, however, insurance companies engage in bad faith insurance practices by denying perfectly valid claims. Understanding why your denial or rejection occurred is of the utmost importance. It allows you to figure out whether or not an appeal is possible.

Below, we list five of the most common reasons for health insurance claim denials:

  1. Incomplete or missing information on your claim form, or billing errors on the medical side
  2. The insurance company simply does not cover what you are claiming, or they deem it medically unnecessary
  3. Your coverage limits are maxed out
  4. The drug or therapy is not part of the health plan
  5. You used an out-of-network service when your plan requires in-network providers

What is a Claims Adjustment in Health Insurance?

Claims adjusters work for the insurance providers and serve to determine the extent of the company’s liability for particular claims. Their main goals are to verify the validity of claims and then, to determine an appropriate settlement amount.

Generally, adjusters perform certain tasks:

  • Interview the claimant
  • Obtain medical documentation
  • Interview legal and healthcare professionals

The adjuster must also gather missing information from doctors, patients, and hospitals about medical procedures, if necessary. They then ensure that the claim form is fully filled out. Afterward, they provide you with updates on your claim about its status, and inform you of the set settlement amount. 

How to Manage Your Denied Health Insurance Claims

It’s a frustrating occurrence when an insurance company denies your claim. After all, you know what your policy says, and you really don’t want your financial security threatened because of something you can’t control.

Following a health insurance claim denial, it is important to take certain steps. With the help of a health insurance claims lawyer, respond to the denial or appeal it with a letter stating why you believe the decision was incorrect. Include all necessary and related supporting documentation and evidence. Remember to focus your appeal on the specific reasons listed within the denial notice.

If the company refuses your appeal, you might have grounds for a lawsuit. Dealing in good faith is important for insurance companies, as health insurance is a form of contract. When insurance companies deny claims wrongfully, this is essentially a breach of contract.

Below, we list examples of these bad faith practices:

  • Evidence fabrication
  • Refusal of evidence
  • Refusal to investigate the claim
  • Delaying the investigation unreasonably
  • Unreasonably adhering to bureaucratic requirements

Work closely with your health insurance claims lawyer to determine the best course of action for your case.

Contact a Houston Health Insurance Claims Lawyer Today

If you believe your health insurance company wrongfully denied your claim, we’re here to help. At Reich & Binstock, we’ll set you up with a highly knowledgeable and experienced Houston insurance and contract claims attorney. We hate to see major insurance companies take advantage of people for their own personal gain. That’s why our goal is to help YOU get the coverage you deserve. To speak with a Houston health insurance claims lawyer today, please call our office at 713-622-7271.

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