The Insured Still Have Options for Denied Claims

Recently Anthem Blue Cross, one of California's largest health insurers, announced it would seek rate increases for many of its customers in the state. On average, the policyholders will see an increase of 8.2 percent, but some premiums could increase as much as 20 percent. Anthem has said the increased premiums and deductibles are to cover projected increased medical costs. Despite what Anthem says, many policyholders feel that the increase is unjustified. Some will seek a ballot initiative to enact reform to allow the California Department of Insurance to limit rate increases.

While California residents must go to the ballot box to hope for any impact on insurance rates, they have mechanisms already in place to settle other issues they may have with their insurers. Current law states that a health insurer must reimburse a claim within a certain time period or provide notice explaining the reasons for denying a claim. An insured party who feels that the denial of a claim or review of a claim is incorrect can request the CDI to review any alleged misconduct or inappropriate denial of a claim.

The CDI, however, only has jurisdiction over certain plans. The California Department of Managed Health Care, for example, regulates plans administered by Blue Cross and Blue Shield. Both the CDI and DMHC have procedures established to help those who feel their insurance provider has wrongly denied or improperly handled their claim.

Insurance Dispute Resolution

The dispute resolution performed by the CDI is a valuable tool for all those who suspect that a proper review of their case did not occur. The first course of action for someone who wishes to dispute a claim is to ensure the insurance plan in question falls under the regulation of the CDI. If that is so, a request for assistance can then be made.

Some of the concerns the CDI can review include improper denial of a claim, misconduct of the health insurer and delay in payment of a claim. In order for a review to take place the insured person will need to provide documentation of the issue in question as well as documentation from the insurer, such as the provider's contract. Because these processes can be complicated, assistance from an experienced insurance lawyer is beneficial.

The DMHC helps health care consumers by ensuring that health plans follow the law and promptly address complaints. When handling a dispute, the DMHC recommends that you speak with your insurance provider and doctor and get any reasons for a denial in coverage in writing. But whatever course of action you decide to take, the DMHC recommends that you act soon. Waiting longer than six months can cost you the right to take any action against your provider.

Contacting an Attorney

It is important to remember that even when an insurance company denies an insurance claim, there are resources that will allow a challenge to the insurer's decision. In addition, even if your claim is denied after CDI or DMHC review, further legal recourse may be available. While the CDI and DMHC can be helpful in some cases, insurance disputes can be complex and seeking the advice of an experienced attorney is often the best approach.