You paid your premiums. Your doctor said you needed the treatment. So, why has your insurance company denied your claim? This is because most customers will never challenge a denied claim or a low offer, and insurance companies know it.
You don’t have to be one of them, though. With the help of a seasoned New York health insurance malpractice lawyer, you can build a case to challenge a denied claim, and get your necessary medical care covered.
Call today to schedule a free, no-obligation consultation with Buttafuoco & Associates: 1-800-NOW-HURT.
What is HMO insurance misconduct?
A Health Maintenance Organization (HMO) is a type of health insurance plan that works through a network of healthcare providers; customers have a primary care physician (PCP), who can then refer individuals out to medical specialists.
These companies owe you a duty to review your claims promptly and without bias. The company then should approve care based on your insurance contract and assist you in negotiating a fair rate for care outside of your plan.
When an HMO fails to hold up these duties, it might be liable for HMO malpractice, also known as “bad faith.” This comes many forms, including:
- Wrongful denial of coverage.
- Offering a low settlement.
- Delay of payment or authorization.
- Misrepresenting policy terms.
- Failure to properly investigate a claim.
- Refusal to approve or refer to specialists.
- Cancelling coverage after a claim is made.
- Denying emergency care.
- Failing to provide a timely and clear appeals process.
- Requiring burdensome, often irrelevant, documentation and records for a claim.
If an HMO denies your claim and it results in harm to the patient, this qualifies as malpractice. Still, HMOs do have a right to deny claims under certain circumstances:
- Treatment deemed not “medically necessary”: This could be something not supported by clinical evidence or appropriate for a given diagnosis. This could include things like cosmetic procedures or elective treatments.
- Care without a referral: Care from specialists, such as dermatologists or orthopedists, often require a referral from your PCP.
- Out-of-network provider: HMOs operate by working with a network of providers with whom they’ve negotiated rates.
When an HMO denies your claim for medically necessary care or provides a lowball settlement, you may be able to file a bad faith claim against the insurer. In many cases, simply letting an insurance company know of your plans to file a bad faith claim will prompt them to give you a higher offer. If the insurer still refuses to offer you an adequate amount, you can take them to court.
How can an attorney help me file my bad faith claim?
If your health insurance company is not treating your claim with the care it deserves, you can fight back. Facing a health insurance company’s legal team, however, is daunting. We recommend working with a New York health insurance malpractice lawyer. They will be able to gather evidence and negotiate with the insurance company. You should be able to focus on getting the healthcare you need.
The New York HMO misconduct lawyers at Buttafuoco & Associates have the experience and knowledge to go up against the biggest insurance companies. We know the importance of medical care for our clients, and we do everything in our power to make sure you get the care you need.
Call 1-800-NOW-HURT to schedule a free case review. We’ll be able to determine if your health insurance provider is potentially liable for HMO malpractice.
If we believe that your insurer broke its legal duty to you and acted in bad faith, we will fight to hold it accountable and get you the settlement you need and deserve.