Be sure to inquire about the specific requirements as they may need to be requested in writing or separate forms may need to be completed. You will need to first request an internal appeal with the insurance company. Once an EOB is received, action should be taken right away to ensure a timely review of your appeal. However, an initial denial does not have to be the final answer. These denials often come in the form of an Explanation of Benefits (EOB) which will have a description of what was or was not paid. So your claim has been denied, now what? Insurance companies have an obligation to provide a denial within a certain time frame which is likely defined in a member handbook. The HMO claimed that the procedure was not “medically necessary,” with little more explanation. Robert's HMO denied coverage for the procedure and he was stuck with a $30,000 bill. ![]() Robert Mendoza: A gentleman who was diagnosed with a rare and likely fatal form of prostate cancer underwent a life-saving procedure at the recommendation of his doctor.And yet, the insurance company upheld their decision to deny his claim based on his involvement in illegal, later changed to “hazardous,” activity leading up to his injury. Bird was never convicted of any crimes or even charged and the details of the events leading up to the shooting are not exactly known. His HMO based the denial on their determination that his injuries resulted from “illegal activity.” However, Mr. Monroe Bird III: A 21-year-old man, who became paralyzed from the neck down after being shot at by a security guard, was denied coverage by his HMO and later died due to the lack of appropriate medical care.Although these denials may seem absurd and not likely to be upheld, let's look at a couple of extreme examples of denied coverage to see the extent these HMOs will go to in order to save some money. Now that we have taken a look at some of the more common HMO denials, it is important to remember that HMOs are looking for any way to cut costs and by denying coverage or delaying payments they are able to do just that. These third-party companies can have different, undisclosed requirements of their own or arbitrary rules which allow them to deny the claims. Many HMOs use third-party companies to review and make determinations on their insureds' claims.Strict and/or not clearly defined notice requirements that often go unfulfilled may cause a claim to be denied.These claims may require additional efforts, including your doctor writing a letter of explanation in support of your claim being paid. Other claims are denied due to treatment that is received out of network or treatment that is considered experimental.Some of the simplest denials are the result of mistakes such as incorrect coding or typos and can be reversed quite easily if caught in time.There are several ways HMOs deny coverage: ![]() Health Insurance Companies Denying Benefits It's time to look at the fine print and learn how you can sue your insurance company if they have denied medical care. ![]() So it must come as a surprise to discover that many HMOs are doing just that and are actually working against your best interests. As such, when reviewing health insurance benefits provided by a Health Management Organization (HMO), most people would not consider the possibility of denied payments or interference with their medical treatment which could have negative outcomes. Health insurance coverage usually provides people with a feeling of security that in the event of an emergency, they will be able to seek the necessary treatment and not accumulate large medical bills. How Can I Sue if My Insurance Company Has Denied Medical Care?
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