We’ve partnered with the law firm of Szaferman, Lakind, Blumstein & Blader, P.C. to offer advice on what you should do if your insurance company refuses to cover your medical treatment.   

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By Robert Lakind

 

When you or your doctor request coverage for a treatment or a medication approval of either remedy is not necessarily automatic.  The insurance company has the option to review the proposed treatment and deny coverage for a host of reasons.  While your doctor knows your condition best, on many occasions, it is a doctor employed by the health insurance company who has never met you, who makes the final decision on which treatments are covered by your health insurance company.  Patients who are seeking experimental treatments, or even treatments that are no longer classified as experimental but perhaps still considered novel, face an especially difficult battle.

 

While insurance companies would obviously prefer that you do not appeal their decisions to deny coverage, under the law you have the right to have your insurance company re-evaluate its initial determination to deny coverage of a particular treatment or medication.  Furthermore, in the State of New Jersey, depending on the type of health insurance plan you participate in, you may even be entitled to have an independent State Board review your insurance company’s determination.

 

Relying on this internal review process has many benefits, including:

 

  • The insurance company cannot charge you for undertaking this internal appeal.

 

  • Generally, the insurance company during the internal appeals process cannot introduce new evidence, meaning they have to support their position, which is now under greater scrutiny, with only the documents they relied upon to make their initial determination.  As some insurance companies do not undertake the most diligent review during their initial determination, this can actually be a benefit for you, as it limits the evidence you would be required to refute.

 

  • Your doctor is permitted to write a letter on your behalf as well as submit any reports he or she deems relevant to your condition during this internal review process.

 

  • You are entitled to have a lawyer represent you in the internal appeals process.  The attorney’s fees you should incur in this internal review process should be a fraction of what you would pay if you instead decided to take your insurance company to Court, and

 

  • While litigation may take years to complete, this process can generally be completed in three months, and expedited if your condition warrants.

 

While success in any of these internal appeals process cannot be guaranteed, this information may help you if you are faced with a denial of coverage by your medical insurance company. If you are faced with this problem, make sure you are successfully represented in getting the health insurance coverage that you are entitled to and need.

 

We’ve partnered with the law firm of Szaferman, Lakind, Blumstein & Blader, P.C., to bring you this advice.  If you have a question on a legal issue, you can send it to the firm by texting the word ‘LAW’ to 89000, or email them directly at mailto:question@szaferman.com.