Denied Health Insurance Claim Lawyer

Unqualified Nurses and Doctors

Health insurance companies all too often have unqualified medical personnel reviewing claims for treatment from their policyholders. An example would be when a policyholder requests coverage for radiation treatment for cancer, and the insurance company assigns a family practitioner to decide if the treatment is covered. A policyholder has a right to expect their claim to be carefully and thoughtfully reviewed by a doctor or nurse with the proper qualifications to understand the medical issues and make a fair decision about coverage for the treatment. Unfortunately, this does not often happen.

Doug Terry took on Aetna in court for denying a cancer treatment claim. CNN interviewed Doug about another case involving an M.D. working for Aetna who made a decision on a claim without review of the medical files.

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Lack of Proper Training Can Lead to Unjust Denial of Health Insurance Claims

In order for an insurance company to meet its duty of good faith owed to its policyholders, it must properly train the people it assigns to decide claims on what the duty of good faith requires the company to do. In other words, how can someone working at a health insurance company comply with the duty of good faith under the law if they don’t even know what they are required to do to comply with the law? The answer is: they can’t. This just makes common sense. But, incredibly, all too often health insurance claims are being decided by insurance company employees who have not been given the proper training on how to handle a claim in good faith.

Overworked Doctors and Nurses Deciding Health Insurance Claims

Health insurance companies often put a great deal of pressure on their employees to handle far too many claims in far too short of a time. The negative effect of this for policyholders is that doctors and nurses deciding health insurance claims often fail to spend enough time reading the medical records, the insurance policy language and the appeals sent by treating doctors before deciding claims. A policyholder is entitled to expect an insurance company will at least spend the time necessary to develop a full understanding of a claim before making a decision. Unfortunately, all too often, the rushed decisions made by health insurance companies are “rubber stamp” denials.

Biased Nurses and Doctors Deciding Claims

The nurses and doctors deciding a policyholder’s claim should not be placed in a conflict of interest situation, but should instead treat the policyholder’s interests with equal regard as the insurance company’s interests. If those nurses and doctors are compensated in a way that gives them a financial incentive to deny policyholders’ claims, a real danger of bad faith claim denials exists. An insurance company that pays its claim decision-makers in any way based on the number of claims they deny or based on the profit of the insurance company risks bad faith claim denials.