A report by Capital Public Radio, based on information from the California Department of Managed Health Care, when patients appeal their denied health care services through a third party, they win their appeal approximately 50 percent of the time. This is because there are a variety of problems that could result in an appeal being wrongly denied.Although many patients would argue that their claims are unfairly denied to increase profits - an argument that may have validity - according to the report, there are other problems that can arise. These include information being incorrectly entered into the computer system or human errors when reviewing a file.
National information about denials varies among the insurers, a 2011 report from the Government Accountability Office (GOA) found. Although the average denial rates for the first three months of 2010 were 19 percent, 25 percent of insurers had denial rates of higher than 40 percent. That means that of all policyholders filing a claim with those particular companies, more than 40 percent had their claim denied.
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The GAO report noted that not only did appeals frequently result in a reversal of the denial, but that in some cases complaints resulted in financial recoveries for policyholders who had their claims wrongfully denied.
So although having an insurance claim wrongfully denied is frustrating, policyholders can be successful either appealing their situation to the insurance company or filing an appeal with a third party. In some cases, lawsuits have also resulted in reversals of coverage and financial recoveries for policyholders.
READER COMMENTS
Anita Rutherford
on
Eventually, between each one I went to wasted all of the time I had to appeal the matter and did nothing in the end which cost me my appeal time they gave of 180 days.
I have been actively seeking assistance on the matter, but keep running into the same problem. And as far as the Bad Faith I am referring to...approx. 2 weeks before they closed my claim...the insurance company lied to get me to accept far less benefits than what they actually owed me, for approx. 7 years of retro-active and present and future benefits...by saying they needed several more Physicians and a few more months to review the PHYSICAL health portion or records in my claim - after having it and allegedly reviewing it for 09 months declaring more time was needed to see if I was eligible for additional benefits. That was basically a Bait and Switch tactic ...that because of the size of my entire claim...(10 years worth of records and information they requested at the time I applied.)
When I requested my entire claim file and other things that should have been there as well that they were supposed to gather weren't there. Major things such as the actual complete STD and LTD Insurance Applications that they or someone else filled out, without my consent or ever providing me a copy of to know exactly what was submitted for them to make their determination. In other words, to this date...I have no copies or absolutely no idea what information they put on or left off of the documents.
And I would like to know because my Physicians say no one from the company contacted or sent them anything anything to fill out...period.
I also found copies of various policy documents that did not match the one provided by my employer which neither they nor my employer ever provided to me at any point of when I applied for benefits or prior to or after I applied for benefits. What I got, is what the insurance company sent me after they closed my claim and sent me my Administrative Claim File.
Also- a majority of information pertaining to me as a Law Enforcement Officer such as Facility Incident Reports that I was involved in directly which is how I got diagnosed with PTSD, Anxiety, and Depression (a.k.a. the Occupational Mental Illnesses which was the only thing they compensated me for...declaring they needed more time for the numerous PHYSICAL health disorders I have)...they also didn't return any of my Law Enforcement Job Training, Education, Experience, Awards and Achievements and also a copy of my Law Enforcement Job Description. According to the Disability Analyst who handled my claim...she said if it wasn't in the box (which was labeled box 1 of 2) ...then they didn't get it. To this date I have yet to receive a box 2 of 2 from them.
So, yes I was trying to appeal their decision...but legally even so, how could I do so in expecting to have a different outcome if what I submitted was never returned or included in my Claim File which was my most important documents and information that verified the actual onset, continuation and duration of all of my PHYSICAL health related problems that started and existed throughout my employment which eventually led me to resign 3 years later in addition to enduring massive amounts of stress as described in the incidents and mandatory overtime I had to work due to low staffing and no additional help.
When they didn't send me my Job Description, Achievements, Incident Reports which clearly showed the level of stress I actually dealt with from day to day...or the copies of each Application someone somewhere from their company filled out for me, my employer and my Physicians without our knowledge or consent for STD, LTD, Life Waiver of Premium - and other important related documents - in addition to them not ever contacting any the Physicians or Therapists in my medical records who actually diagnosed and treated me for any of my conditions...and then lying to me to get me to accept Occupational related benefits rather than all the other benefits I was eligible for...how could anyone expect a different outcome. How could I appeal when they left so much out and expect a different decision if you can only use what they selectively included in my file for an appeal and act like they never received all the rest yet never made it a point to tell me they never got it until after they closed my claim and I noticed it missing from my Claim File they returned to me in order to appeal.
They wasted 9 months delaying and stalling, then lying...just to get me to accept something no where near the amount they truly owed me as referenced prior.
And as for them needing the several more Physicians to review my several health comlications and associated records...and few more months to complete the review...they only used 1 of their own employee Physicians and a RN to determine the final outcome of denying me the rest of my benefits. Bait and Switch. Period.
Is there anything I can do at this point? I have filed a complaint with the Federal Trade Commission...but am not sure where to go from here as to if there is anything else I can do since the attorneys who I went to said they were going to see if they could assist but didn't do anything in the end but waste all of my appeal time, in a nutshell.
Does this classify as Bad Faith??? And can you help?
Thanks for your time.
were never sent back to me...as if they were never received.
Tonia Groves
on
My Employer pays the benefits but uses Liberty Mutual as their third party vendor to do the underwriting and administering of the claims.
My condition, which by the way I tried to mitigate any loss from work due to stressors that can exacerbate a potential Fibromyalgia "flair-up" by going to my HR department on two separate occasions to discuss the problems with a new Line Manager I was given on April 4, 2014. I also asked for put in for a formal LIne Manager change on the morning of April 30th.
I was just diagnosed with Fibromyalgia in October of 2013. Where I have managed to keep my stress levels down so as to not miss/allow this disease to interrupt with my job. If I had a few bad days up until May 1, of this year I used my own sick time to rest.
I made it very clear that this horrifically painful "flair-up" which caused me to utilize some of my FMLA to help heal was a direct result of 12 to 14 hour work days as well as working weekends (I'm salaried exempt) due to the hostile, harassing, demeaning Line Manager that I had been given on April 4, 2014.
Because I didn't lie to Liberty Mutual when they were doing the initial intake and asked if I had any other outside stressors other than work and I said no "I've been blessed with a good family and friends" is where things went down hill from there. I believe this denial is a direct result of my company not wanting this to show the incompetent people they put in charge to manage people.