Denied Health Insurance Claim in Oklahoma? Learn How to Fight Back Today
Common Reason for Oklahoma Health Insurance Denials
Health insurance companies can deny claim payouts for several reasons. Here are some of the most common rationales that insurers offer when they refuse to pay for your treatment.
Pre-Existing Conditions
The Affordable Care Act (the ACA) prohibits a health insurer from refusing to cover you for a pre-existing condition. However, not all health insurance plans are subject to the ACA.
Short-term coverage plans (policies), for instance, are not subject to the ACA and thus, an insurer can deny a claim as a pre-existing condition under these policies.
Before an insurance company can deny a claim as a pre-existing condition, it must be sure that it qualifies as one under the policy language. The definition of “pre-existing condition” usually varies amongst each policy. Generally, however, policies define “pre-existing condition” as a condition that the insured had, or should have, received treatment for before the policy’s effective date. This look-back period is usually 2 years but can vary.
Insurance companies frequently take broad liberties in deciding that a condition is a “pre-existing condition.” So, just because an insurance company says a condition is “pre-existing” does not necessarily mean it is. Insurance companies don’t want you to know this, but as the policyholder, you have the right to challenge the insurance company’s decision. In Oklahoma, the law gives policyholders the right to sue the insurance company for denying a claim.
Policy Exclusions and Limitations
Insurance companies may deny claims if the requested service is “elective” and not “medically necessary.” For example, cosmetic surgery is rarely covered. The classification of a procedure as “elective” can frequently be subject to interpretation. Insurance companies often adopt the most restrictive interpretation, even when the law mandates a broader approach.
Another common reason for wrongful denial is when the insurer restricts your treatment as a cost-control measure. For example, your insurer may want you to try prescription medications before resorting to more costly options like surgery. Just because the insurance company has this requirement in place, does not necessarily mean it is the law. The requirement may be arbitrary, for instance. Under Oklahoma law an insured has a right to sue an insurance company for setting arbitrary requirements.
You Waited Too Long Make a Claim
Health insurance policies often have a time limit within which you must file a claim. This period usually ranges from 30 to 90 days. Missing this deadline typically results in automatic denial. Automatic denial means your claim will be denied regardless of its validity due to a technical deficiency. However, such deadlines are not always enforceable under Oklahoma law.
You Did Not Get Advance Authorization for Certain Medical Services
Health insurance companies can deny a claim for failure to obtain pre-authorization. This can apply to services that insurers consider to be “non-routine.” Examples include hospital stays, surgery, and behavioral care.
Prior authorization is impractical and potentially fatal to policyholders in emergencies requiring life-saving surgeries. Many insurance policies waive pre-authorization for emergency care. The Affordable Care Act mandates that insurers cannot require prior approval for emergency surgeries. However, insurers may attempt to deny claims retroactively, arguing the situation was not indeed an emergency but a denial for this reason and other similar ones may not be legal under Oklahoma law.
Your Treatment is Not Making Enough Progress
For long-term care, if the insurance company decides your treatment is no longer resulting in improvement, it may cut off payment. This typically involves rehabilitative treatments such as physical therapy, where insurers expect measurable progress within a specific timeframe. Policyholders should understand their right to sue insurers for wrongful denials on this basis, especially if they feel the ongoing treatment is successful in managing subjective, non-quantifiable pain.
Technical Errors
Sometimes, insurers deny claims because someone made a mistake. Medical treatments all have established codes that insurers use to authorize reimbursement. However, the insurer may reject the claim if someone accidentally inputs the wrong code for you. In more egregious situations, a health insurance company might misidentify you in its system or even lose a claim during processing.
Many insurance companies now rely on automated claim review processes. Computerized systems make it easy to deny your claim with minimal oversight. While efficient, this approach increases the risk of wrongful denials by removing the human element of the claims review process. Technical errors are seldom the policyholder’s fault, and insurers can be sued for wrongfully denying claims on such grounds.
You Went Outside Your Provider Network for Care
Some Health Maintenance Organizations and Exclusive Provider Organizations restrict reimbursement to their networks. Generally, these will not pay for any out-of-network care you receive other than emergency treatment. Other plans may not preclude out-of-network reimbursement but may make you pay more out of your pocket for them.
What if Your Health Care Insurer Denies Your Claim?
Claim denials in Oklahoma occur more often than consumers realize. Insurance companies, through trained adjustors, look for any reason to deny coverage. Remember, insurance companies exist to make a profit, not for charitable purposes.
Don’t Give Up Without a Fight
In basketball, there is a saying: “You miss all the shots you don’t take.” Similarly, many consumers accept health insurance denials without question, thereby missing their opportunity to fight for coverage.
How bad is this problem? Consider: in 2021, less than one percent of healthcare consumers with denied claims bothered to appeal the denial. Put another way, fewer than one of every 500 people with denied claims did anything to appeal the decision.
Before accepting a denial, check your health insurance policy. Also, check your insurance company’s website to see its internal appeal options. Then, appeal. The worst that can happen is that the insurance company will refuse to reconsider. But at least you will be one of the rare people who bother to try. Even a low-percentage shot is better than taking no shot at all.
If an appeal is denied, the only step left is to sue the insurer. Contact Aizenman Law Group today if this happens for your free consultation.
How Often Do Oklahoma Health Insurers Deny In-Network Claims?
A health insurance company’s rejection of your health insurance claim can happen in two ways:
- The insurance company informs you in advance that it will not pre-authorize a claim.
- After you’ve received treatment, your insurer refuses to cover the cost.
Nationally, insurance companies deny about 17 percent of in-network insurance claims. The denial rate varies considerably among insurers. Some accept almost all claims, with only a two percent refusal rate. A few others deny up to half of the submitted claims. In one extreme example, an insurer denied 80 percent of claims in 2020.
Oklahoma is in the middle of this range. The state’s overall rate of health insurance in-network claim denials is slightly more than 16 percent. This means you have around a one-in-six chance of your health insurer rejecting payment for in-network healthcare.
Contact the Aizenman Law Group to Help with Your Wrongfully Denied Claim
Enforcing your rights when a health insurance claim is wrongfully denied is no small task. At the Aizenman Law Group, our experienced Oklahoma wrongful insurance claim denial attorneys know how the insurance process works and have successfully recovered millions of dollars for claims wrongfully denied for reasons discussed above, such as “pre-existing condition”, technical errors, etc.
Best of all, the insurance attorneys at the Aizenman Law Group work for you on a contingency fee basis. You owe us nothing if we don’t succeed in recovering for your denied claim.
Don’t miss your chance to fight back. Consult with an Aizenman Law Group at 918-215-8856 at any time day or night. Don’t accept a health insurance claim denial lying down. If you’re dealing with an Oklahoma Health Insurance denial, let our Tulsa-based attorneys Aizenman Law Group guide you through your legal options.
