The frustration of receiving a healthcare claim denial can leave you feeling confused and worried. Losing access to benefits can be both disheartening and financially distressing.
However, insurance laws and regulations exist to assist in these situations. This article explores these laws and sheds light on how they can be your ally in reversing an unfair denial.
Take the first step in turning the tide. Dive into our guide and get a referral to a local insurance lawyer today.
Insurance Laws That Can Reverse Denied Claims
Employee Retirement Income Security Act (ERISA)
ERISA is a pivotal federal law from 1974 that governs most private health and pension plans. It mandates that policyholders receive crucial details about features and funding. Accordingly, it has standards for participation, vesting, and benefit accumulation.
ERISA also outlines financial duties to those who manage these policies and creates an appeals process. Most importantly, it empowers you to challenge breaches of fiduciary duty or to seek owed benefits.
ERISA has a notable influence on healthcare claims. It dictates the procedures to process and manage them. One of the most vital obligations it creates is to provide the following for denials:
- Specific reasons for the rejection
- Details of the plan’s review procedures
- Time limitations
- Rights under ERISA
How Lawyers Use ERISA to Reverse Denials
An attorney can use ERISA in court to enforce its guidelines and protections for your health insurance. They leverage this law to scrutinize the decision and ensure adherence to procedural standards. This scrutiny involves confirming whether the insurer met these criteria:
- They provided a detailed and explicit reason for the denial
- They honored the appropriate timelines for processing the claim
- They supplied adequate information about the right to appeal
Also, an attorney can sue if the internal review does not overturn the denial. They would argue your insurer violated ERISA regulations, such as failing to conduct an unbiased review. Winning this litigation could lead to a reversal of the denial and additional penalties against the insurance company.
Affordable Care Act (ACA)
The ACA marked a transformative phase in the U.S. healthcare system. Its primary objectives were the following:
- Improve the quality and affordability of health insurance
- Decrease the number of uninsured
- Shrink healthcare costs
The ACA brought several reforms to meet these goals and optimize the insurance market. It extended insurance access to millions, including those with pre-existing conditions. Furthermore, it focused on eliminating discriminatory practices and improving consumer protections.
How Lawyers Use the ADA to Reverse Denials
An attorney can focus on the non-discrimination and equal access sections to reverse denials. For example, the ACA mandates that healthcare services be accessible to disabled individuals. This requirement means there should be reasonable adjustments to policies and practices. Therefore, your representation may argue the denial was a failure to offer accommodations.
Furthermore, an attorney can claim that your condition qualifies as a disability. This approach is potent if the service is typically available to non-disabled people. In response, your representation may file a complaint with state or federal agencies against the insurer. This action can ensure the enforcement of your rights.
State-Specific Laws
State-specific regulations add another complex layer to the U.S. healthcare system. Each state passes its own legislation that results in varied legal frameworks. These differences can extend from coverage mandates to how to manage appeals. As a result, your claim and the protections you enjoy depend on where you live.
Several states have laws that extend federal mandates. A few examples seen in recent years are:
- Heightened standards for insurer accountability and transparency
- Expedited claims processing
- Rigorous criteria for claim denials
- Independent review processes
Knowledge of your state insurance laws is vital when confronting a denied claim. Otherwise, you cannot hope to appeal a decision or identify violations of your rights.
The Appeals Process
Challenging a denied healthcare claim involves a structured process. It typically unfolds in two stages: an internal appeal and, if needed, an external review. The first asks the insurer to reconsider its decision. The second involves having an independent third party offer an unbiased opinion.
Consult With an Insurance Lawyer
Knowledge and expertise are arguably the most potent allies when you receive a denial for a healthcare claim. It helps to take the time to examine laws like ERISA and the ACA. However, some cases call for legal training and experience.
Are you grappling with a denied healthcare claim? Then, consider meeting with a local attorney. We have representatives available 24/7 to refer you to one.
Call (866) 345-6784 or complete this online form today!
About the Author
Aaron is a professional legal writer with a B.S. in English Education from Southern Illinois University – Carbondale. He has written, published, and edited thousands of legal articles for RequestLegalHelp, which has connected over 5 million people to legal help in the United States.
With over five years of experience writing thousands of legal articles for law firms across the U.S. and Canada, Aaron specializes in covering federal, state, and city-level legal issues ranging from auto accidents to wrongful terminations.
