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Houston Health Insurance Claims Lawyer

health insurance 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 are the Duties of a Heath Insurance Company?

All health insurers have certain duties and responsibilities to their policyholders. If these companies wrongfully deny a valid health insurance claim, they are acting in bad faith. Bad faith behaviors from insurers could bring up a serious legal issue in which they open themselves up to liability. Below, we list the specific duties and benefits owed to insured persons. These are the good faith practices of insurance providers. Their duties are to:

  • Defend Policyholders: Let’s say a third party brings healthcare claims against an insurance company’s policyholder. The company has a duty to defend its policyholder against claims made against them.
  • Indemnify: If you, as a policyholder, are found liable for the losses that another party suffered, then your insurance company must pay for those losses.
  • Good Faith and Fair Dealing: Bad faith practices occur when companies fail to uphold the standard expected of them. When they fail to protect their policyholders, they may face a case involving insurance bad faith
  • Quickly and Fairly Investigate and Handle Claims: An insurance company is expected to investigate the claims of their clients in a timely manner, as well as provide policy benefits for those claims.
  • Settle Fairly According to the Health Insurance Policy: An insurance company must settle all insurance and disability claims according to the policy of the insured. This also includes adhering to policy limits.
  • Disclose Conflicts and Issues to Insured Persons: If any problems arise with medical providers, insurance benefits, or other aspects, the company is required to notify the insured in a reasonable amount of time.

When to Hire a Lawyer for a Claim Against Health Insurance Company

lawyer for health insurance claims

If you believe that your health insurance claim was wrongfully denied, we recommend speaking with an insurance denial attorney right away. However, most health insurance plans have time limits that restrict the amount of time you have to file a lawsuit. Because of this, we highly recommend filing your claim as soon as possible to avoid a dismissal of your case in court.

The best time to work with a law firm for your case is immediately after you receive the denial notice. However, you can work with someone in the legal community at any point after you initially submit the claim. This includes the appeals process with your health insurer. 

We can also initiate lawsuits for healthcare claims to try and seek payment for those claims. Our knowledge and experience allow us to look over your health insurance plan and evaluate the specifics of your case in order to give you a fighting chance. 

What Are the Reasons for Health Insurance Denial?

Denial of insurance benefits, while frustrating, sometimes has valid reasoning. However, many insurance companies use valid reasoning to deny claims under false pretenses. This is because their ultimate goal is to minimize losses and maximize profits. They have a financial incentive. Even with an obviously legitimate claim, they may still deny it. Some common possible reasons why your insurer denied your claim include the following.

  • They may claim your medical care was not medically necessary.
  • Sometimes, paperwork and forms can get mixed up or lost. When this happens, you may receive a denial letter.
  • Maybe your treatment was very expensive. If the company asked you to try a cheaper treatment first and you refused, they may deny the claim.
  • These companies have mountains of rules and procedures to follow. If you miss even one small step, this could result in denial.
  • Should you file after the time limit for your medical coverage expires, you may lose your right to those benefits.
  • If you go to a provider who is not in your network, you may not be able to have those medical expenses covered.

What Is the Difference Between a Rejected Claim and a Denied Claim?

Rejection happens during the processing portion of your claim. Generally, this happens when there are errors found in your claim. It could also happen because you did not meet certain information requirements. Denial happens after processing your claim. They are denied because the company has determined that your claim is not payable.

What Type of Lawyer Covers Health Insurance Claims?

health insurance claims lawyer

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 lawyer

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, an 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?

How Long Does an Insurance Company Have to Pay a Claim in Texas?

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?

lawyer for health insurance 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 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

health insurance claims lawyer

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.

Do I Need a Lawyer for My Health Insurance Claim Denial?

health insurance lawyer

While it is possible to appeal a claim denial on your own, it is much less stressful to do it with the help of an experienced attorney. Dealing with large insurance companies that don’t have your best interests at heart can feel like an uphill battle. For this reason, Reich & Binstock represents those who feel they’ve been treated unfairly by their insurer. We can offer a free case evaluation in which we investigate the circumstances surrounding your claim. If your insurer is acting in bad faith, we can find out and get you the coverage you deserve. 

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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