Recovering Denied Insurance Claims Since 1985.
If your Insurance claim is denied, Merlin Law Group's insurance denial attorneys can help. Getting your disability, life, health, or long-term care insurance company to pay your claim can be a daunting task. We understand the task can be even more daunting when you are struggling physically, emotionally, or mentally. With decades of experience in representing insurance policyholders in contractual and extra-contractual (bad faith) disputes, we look forward to helping you successfully manage these difficult times by, in part, obtaining appropriate compensation from your insurance company.
If you or a loved one is out of work due to a disability and the insurance company is not picking up the slack on lost income...
LONG-TERM CARE INSURANCE CLAIM
A friend, loved one, or yourself has been dismissed from an assisted living facility or nursing home because the insurance company was not fulfilling its contractual obligations...
If you are unable to receive needed healthcare because your insurance company is not authorizing payment, or your insurance company is refusing to cover previously received healthcare...
Whether a friend or a loved one’s life insurance claim has been denied because of supposed lapse in premium payment, or one’s life insurance claim has been denied because of supposed insurance application misrepresentation...
UCR, Usual Customary and Reasonable
By Nicole Vinson, Esq.
ERISA Insurance Claims
By Nicole Vinson, Esq.
Health Insurance Claims
By Nicole Vinson, Esq.
Geez, As If Processing A Health Insurance Claim Wasn’t Already Tricky Enough – Here Comes ICD-10
So, come October 2015, medical professionals (and agents who process the bills of medical professionals) in the United States will be required to use ICD-10. “ICD,” by the way, is short for International Statistical Classification of Diseases and Related Health Problems. In a very small nutshell, the ICD schema is the method by which clinical information (such as diagnoses) is charted and insurance claims are processed.
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Childbirth Insurance Claims, Pregnancy Bills
Insurance claims in general tend to be complicated, but it appears as of late that healthcare insurance claims, specifically those related to pregnancy and childbirth, have increased in complication. One prediction for the increase in pregnancy and childbirth insurance claim denials and delays is this: the science behind pre-birth child and mother care and post-birth child and mother care is ever-evolving. Some health insurance companies are having trouble keeping up with the evolution of pregnancy and childbirth healthcare and are unable to always fulfill full and proper coverage for mother and child.
Whether you are a physician who handles billing on your own or you have in-house personnel dedicated to billing and insurance claims or you outsource your billing and insurance claims to a billing agent, the attorneys at Merlin Law Group are here to assist you. When an insurance company delays, denies, or underpays the insurance claim, Merlin Law Group is here to help you, the physician.
Long-Term Care Providers Billing Problems
Merlin Law Group represents not only long-term care policyholders, but any long term care faciliy, nursing home, or assisted living facility that has an assignment of benefits from the policyholders. When your patient may be struggling mentally or physically it may be easier for our attorneys to work with the facility rather then the policyholder.
Health Insurance Explanation of Benefits
An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf. The EOB is commonly attached to a check or statement of electronic payment.
Do you ever have difficulty determining how a certain amount has been deemed as patient responsibility? Have you ever had trouble figuring what is applied to your annual out of pocket max? Have you ever asked yourself what is a deductible? What is a co-pay? What is the difference between in and out of network?
Health Insurance Denied Medications
Medical prescriptions can cost some patients thousands and thousands of dollars. Medical prescriptions are more frequently being denied insurance coverage. A possible example includes: a health insurance company attempting to force generic prescriptions on their policyholders, when in fact their medical provider is insisting on name brand prescriptions.
Health Insurance Denied Paying For Surgery
When surgery is needed, it is typically at a high cost. Whether or not your health insurance policy requires you to have a pre-approval, sometimes referred to as pre-certification, for surgery, you should always get a pre-approval. Most likely, your health insurance policy will dictate, in very fine print, that pre-approval does not constitute a coverage decision.
Claiming Your Life Insurance Policy
By Nicole Vinson, Esq.
If you have not yet purchased a life insurance policy and are interested in doing so, it is critical that you diligently and thoroughly read through the document, ensuring all information and facts are correct. If you are coping with the loss of a loved one shortly after the life insurance policy was issued, the insurance company might possibly suggest something known as the contestability clause.
In most states, there is a 1-2 year window that is referred to as the insurance company's contestability time. This indicated window of time is when the insurance company can evaluate the information on the application and decide whether those facts are in fact enough for the insurance company to deem the insurance coverage proper.
Medical Providers And Billing Agencies: There Are Things That Should Be Done Before Sending The Patient To Collections Or Writing Off The Medical Bill
This follows up on the Merlin Law Group’s attendance at an April 2015 conference put on by the Healthcare Billing and Management Association (HBMA). As I discussed with several folks at the HBMA conference kind enough to stop by the Merlin Law Group’s exhibitor hall booth, medical providers and / or billing agencies should consider looking into the contractual, legal, and / or factual (im)propriety of the health insurance company’s claim denial or partial payment before sending patients into collections or writing off the medical bill.
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Paying The Bills: April 22-24, 2015, Healthcare Billing and Management Association
Spring Educational Executive Symposium (Orlando, FL)
It is not uncommon for patients to assign their insurance benefits to medical providers. And, regardless of a possible assignment, it is not uncommon for medical providers to handle the processing of claims with the patient’s insurance company. From the medical provider’s perspective, what happens if the patient’s insurance company denies claim payment?
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Getting The Claim Decision In Writing
Sometimes, insurance companies will verbally convey a claim decision to a policyholder. If this happens to you, it is imperative that you ask the carrier to memorialize its claim decision in writing. Why is it important to have the carrier reduce its claim decision to writing? Well, there are several different reasons, but here are a few examples.
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Combating Carrier Delay
All too often, potential clients find themselves dealing with insurance company foot dragging. The most common example of foot dragging is the insurance company’s taking an inordinate amount of time to provide the policyholder with the most simple of documents, the policy. Well, what to do about that? No need for me to reinvent the wheel … here is an article entitled Claim Delay 101 that I published in December 2013:
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How Do You Find Out Whether The Deceased Had Life Insurance?
When a family member or friend passes away, grief is typically the first thing survivors need to overcome. And, while grieving, survivors usually also have to try to coordinate funeral logistics, burial arrangements, memorial services, etc. During these difficult times, one of the last things likely on survivors’ minds is whether the deceased had life insurance. But, shortly after a passing, this is something I recommend survivors try their best to look into … according to a February 2013 article from Consumer Reports Magazine, “At least $1 billion in benefits from misplaced or forgotten life-insurance policies are waiting to be claimed by their owners.”
Noteworthy California Disability Insurance Decision Regarding The Regulatory Duties Of
Departments Of Insurance / Insurance Commissioners
There once was a California disability claimant named Cassaundra Ellena whose Standard Insurance Company disability claim was denied as a result of the policy’s “any occupation” / “own occupation” language.1 Eventually, Ms. Ellena took issue with the California Department of Insurance regarding such language.
What Law Governs? ERISA Or Not?
Generally, if you are part of a group health insurance plan, disability insurance plan, or life insurance plan, your claim (and related litigation) will be governed by the federal body of law called ERISA (Employee Retirement Income Security Act). In my opinion, ERISA is pro-carrier in most jurisdictions. So, in my opinion, you should try to avoid ERISA like the plague.
What Your Disability Claim File Should Include
A disability claimant’s maintaining a thorough claim file will greatly assist a policyholder attorney in unraveling a claim denial. Here are some examples of steps that disability claimants should take toward laying a good foundation for policyholder attorneys like me.
Don’t Blindly Trust Your Health Insurer’s In-Network Medical Provider List
Most health insurance companies make their in-network medical providers list available to policyholders, oftentimes via the carrier’s website or a printed directory. And most health insurance policies place the burden (or at least the initial burden) of locating in-network medical providers squarely on the shoulders of the policyholder. Well, actually, this should not be too much of a “burden” equipped with the carrier’s medical provider list, right? Hum, not so fast…
Notes To Selves Regarding The Denial Of The Rolling Stones’ $12,700,000 Claim
I am not privy to the policy language underlying the Rolling Stones’ claim, so I cannot opine as to the (im)propriety of the carrier’s claim decision. But the above article inspired me to point out a few things to life and disability insurance claimants / policyholders.
Just How Material Are Your Life Insurance Application Representations?
As discussed in other articles featured on this website, one of the first things a life insurance company will turn to when deciding whether to pay a claim is the life insurance policy application. Why? Because there are very few ways (when compared to other types of insurance claims) for a life insurance company to try to deny a claim and voiding the policy ab initio (i.e., rescinding the policy as if it never existed) due to supposed misrepresentations on the life insurance policy application is one such way.
Is Your Treatment or Care Medically Necessary?
In the health insurance and long-term care insurance arenas, an all-too-common basis for claim denial is that the subject treatment or care was not medically necessary. “Medical necessity” is an amorphous concept, for several reasons. Perhaps the most obvious reason is that treatment plans often account for the individual just as much (if not more) than the diagnosis; i.e., a particular kind of treatment may be necessary for one of two patients presenting with the same condition, but not for the other.
Is Your Disability Occupationally Disabling?
I often hear something like this from disability claimants: “I don’t get it … all of my medical providers uniformly attest that my ailments are disabling, yet the carrier is still giving me a tough time … what gives?” Well, when I look into the “what gives” part of that, I sometimes find that the carrier is grappling with the mental or physical component of the claimed disability; i.e., debating the findings and / or opinions of the policyholder’s medical providers. But, more often, I find that the carrier is grappling with how the disability compromises the insured’s ability to maintain employment.1 So, what can you do to help quell (or even preempt) the carrier’s concern that your disability does not preclude you from maintaining employment?
Do You Have The Most Personally Suitable Life Insurance?
All too often I have life insurance beneficiaries come to me along the following lines: “Gosh, I was shocked to discover that there were no benefits payable to me under the deceased policyholder’s life insurance policy … what’s the deal?” Well, folks, that is sometimes not true; i.e., sometimes the insurance company is wrong and we need to remedy that. But, oftentimes, that is unfortunately true because the life insurance policy was set up as an investment mechanism with little (if any) guaranteed death benefit. This article is aimed at providing a brief overview of some of the most common life insurance products on the market and the intent of same, so that you are not someday surprised to learn that a lump sum death benefit is unavailable.
What To Do About The Independent Medical Examination?
In the insurance context, an Independent Medical Examination (“IME”) rears its head most often with respect to disability claims. The IME is a claim investigation tool for the insurance company, whereby the carrier is attempting to assess the claimant’s physical condition independent from a treating physician’s opinions. Many of my disability clients are quite wary of the insurance company’s IME request … not because my clients’ physical conditions are somehow illegitimate (indeed, I only represent folks with legitimate ailments), but because of the not-so-secret reality of IMEs typically being a trap. More specifically, the IME is typically an insurance company’s attempt to lay a foundation for claim denial, and the IME physicians retained by insurance companies typically know exactly what the insurance company wants him / her to write. So, what do we do about the good ol’ IME?
Post-Treatment Follow Up With Health Insurance Companies
So, I have written about the importance of seeking your health insurance company’s pre-authorization / pre-certification of a medical procedure that you will subsequently be claiming with your carrier. But what about following up with your health insurance company after you have received medical services and sought coverage for same? Is it a good idea to stay on top of your health insurance company in the wake of medical treatment and claim submission? Absolutely, in my opinion.
Are Stem Cell Treatments Covered In My Health Insurance?
This article (which is precautionary in nature) hits close to home, as I have a friend who is undergoing stem cell transplants for the treatment of scleroderma and is doing so “out-of-pocket.” The “out-of-pocket” aspect of that is a travesty, in my opinion – the current lay of the medical land (stem cell treatments gaining traction throughout the worldwide medical community and meeting with significant success) simply does not square with the current lay of the insurance land (most insurance companies still considering such treatments “experimental”). 1
Long-Term Care Insurance Claims, ALF vs. Nursing Home
There is much to be assessed when exploring long-term care insurance options, particularly the decision of choosing an assisted living facility or a nursing home. The fundamental differences between an assisted living facility and a nursing home are the level of care that a resident receives as well as the amount of freedom allotted to a resident.
Beware of the Ongoing Disparity Between Mental and Physical Insurance Coverages
This article is largely geared toward promoting consumer awareness. The awareness being that those requiring mental health services and / or those who are mentally disabled are still (inexplicably, in my opinion) not treated equally with those requiring physical health services and / or those who are physically disabled. You should keep this unfortunate reality in mind when securing health or disability insurance.
Regarding disability insurance and for example, it is still all too common for disability insurance policies to limit the mentally disabled to a shorter period of benefits (e.g., 24 months). Compare this to the physically disabled, who are, under most disability insurance policies, entitled to receive benefits until age 65 or through their lifetime.
Legislative "Disability" Does Not Necessarily Equal Insurance "Disability"
My disability insurance clients often ask me whether being deemed “disabled” under the Social Security Disability Benefits Reform Act, the Family Medical Leave Act, or the Americans with Disabilities Act, necessitates approval of their disability insurance claim. Because I am often asked this question, I thought it worthwhile to blog about.
Is A Surviving Spouse Liable For The Deceased Spouse's "Uninsured" Medical Bills?
In my health insurance, life insurance, and long-term care insurance practice, I sometimes encounter the tangential issue of keeping the deceased insured’s creditors, such as hospitals and doctors, at bay from the deceased’s spouse until it is determined whether the creditors’ bills should have been paid by the insurance company. This begs the question: notwithstanding any contractual obligation the insurance company may have to pay a deceased spouse’s medical bills, is the deceased’s surviving spouse legally on the hook for such bills?
Life Insurance Denied Due To Lapse In Payment
Today I would like to discuss life insurance denials, one of the worst of its kind. Specifically, I would like to address a life insurance denial due to a lapse in premium payment. Many times, leading up to a policyholder’s unfortunate passing, the policyholder might find his or herself incapacitated to a degree, whether it is physically or mentally. In this condition and predicament, it is highly unlikely that paying a life insurance premium is weighing heavily on the policyholder.
Does Divorce Divest a Former Spouse Life Insurance Beneficiary of Beneficiary Status?
Over the past month, I have learned of several life insurance companies nakedly claiming to divorcee beneficiaries that divorce automatically divested them of beneficiary status under the deceased former spouse’s life insurance policy. This automatic divestment theory seemed extreme, so I did some research.
Health Insurance Claim Denied, Pre-Approved Medical Procedure
Pre-approval for a medical procedure is an imperative precaution when your health insurance policy is concerned. Pre-approval or pre-certification, is an authorization that can be required by your health insurance company to ensure that said medical procedure is necessary and ultimately appropriate for your condition. Always remember that every insurance policy differs, so it is crucial to know exactly what is covered in yours.
We are truly grateful for your help in solving this unfortunate situation. Thanks just doesn't seem enough. We were blessed to find you and will never forget.
–Ron & Melody W.
I want you to know how pleased I am with Merlin Law Group for settling our case against Citizens after they denied our claim.–Esme S.
Suffering many damages and losing hope of recovering from our insurer was a terrible experience. But thanks to Merlin Law Group and their terrific staff, we did realize recovery for many losses.–Joe and Margha B.
We are very satisfied with Merlin Law Groups efforts to resolve our insurance issues with the Hartford. They were persistent and the outcome was successful.