Mansell & Engel Mansell & Engel2024-02-09T19:12:21Zhttps://www.theinsuranceattorneys.com/feed/atom/WordPressOn Behalf of Mansell & Engelhttps://www.theinsuranceattorneys.com/?p=494262024-01-29T22:03:46Z2024-01-29T22:03:46ZWhy was my claim denied?
There are several reasons your claim may be denied. Some are relatively minor reasons that could have a simple solution, while other reasons are more complicated.
Some common reasons for denials include:
Failure to follow proper instructions
Lack of documentation
Missed deadlines
Before you submit your claim, you should review your insurance policy carefully and in detail. Missing a step in the process or not submitting complete or correct documentation can cause an otherwise valid claim to be denied.
Deadlines are extremely important. There might be different deadlines throughout the process and missing just one of them could result in a denial.
For example, there can be a deadline to file your claim and another deadline to submit documentation. If you file your claim in time but miss the documentation deadline, your claim could be denied.
What should I do if my claim was denied?
The first thing you should do if your claim is denied is review the denial letter in detail. The letter must clearly explain why the claim was denied so you understand your options.
If the letter does not have a written explanation that you understand, call your insurance company immediately and find out the reason.
Keep copies of every document you receive related to the denial. This includes any communications between you and the insurance company.
Communicate through email if possible. If you have a telephone conversation, write down the date and time of the conversation, the name of the person you spoke with and everything they told you.
Can I appeal the denial?
If the denial is because you forgot to submit a piece of paperwork or give certain information, the claim may be approved if you submit the paperwork or provide the missing information.
When the reasons are more complicated, you can usually appeal the denial. Each insurance company has their own specific internal appeals process.
Learn the rules for appealing and file an appeal as soon as you can. As with the claim submission process, the appeals process has requirements and deadlines. Missing one of these could cause your appeal to be denied before you even get to a hearing.
How can I avoid a denial in the future?
The best way to avoid another denial in the future is to remember to review the policy requirements before submitting your claim. Sometimes even if you do everything in the process correctly, your claim might be denied because it is outside your coverage limits.
Reviewing your policy to learn what is and is not covered can save you from submitting a claim for something not covered. You can instead explore other options to cover your losses.
Providing your insurance company with as much information as possible can also help you avoid a denial. Letters, photos, reports and other documentation are all important evidence that should be submitted.
Getting a denial letter can be frustrating and scary but remember that you have options and a right to appeal.]]>On Behalf of Mansell & Engelhttps://www.theinsuranceattorneys.com/?p=494242023-12-06T06:23:08Z2023-12-06T06:23:08Zhealth insurance claim denial, you’re certainly not alone. Studies have shown that some insurance companies even deny claims at a rate as high as 49%, with 17% of all in-network claims being denied. Why are these denial rates so hight? Let’s take a closer look.
Top reasons why health insurance claims are denied
Insurance companies can get creative in their justifications for claim denials. That said, here are the tops reasons why health insurance claims are denied:
Services were excluded: An insurance company is going to pay for medical care only if it’s covered under your policy. Therefore, they’re going to look for ways to argue that the care you received falls outside the plan’s coverage. If possible, you should confirm that your care is covered before receiving it. About 14% of all in-network claim denials fall under this category.
Lack of preauthorization: A lot of medical treatment and testing is obtained after recommendations are made by your doctor. But your doctor isn’t going to double-check your insurance policy to see if the recommended treatment is covered. After all, they want what’s best for your health, not your bank account. That’s why about 8% of in-network claims are denied because there was no preauthorization given by the insurance company before securing the treatment or testing in question.
Lack of medical necessity: In 2% of claims that are denied, insurance companies allege that the treatment obtained wasn’t medically necessary. In other words, the insurance company indicates that the treatment that your own doctor said you needed was something extra that you actually didn’t need.
All other reasons: Shockingly, 77% of all in-network claim denials are classified as “all other reasons.” What does that mean? Good question. There’s no definition provided for these causes, but it might include things such as lack of information. Again, this highlights how the insurance company tries to be tricky in its attempts to deny your claim, and the various options they have to get where they want to go.
Insurance claim denial appeals
While 17% of in-network health insurance claims are denied, only a fraction of those who are subjected to a claim denial end up appealing. Yet, appealing a denial could get you the outcome that you want. You simply need to understand your policy, the insurance company’s stated reason for your claim denial, and how you can present evidence that’s contrary to that justification.
This will require some legwork and close reading on your end, but if you’ve been hit with a massive medical bill due to a claim denial, then you owe it to yourself to take action when justified to do so.
Are you ready to appeal your claim denial?
If so, then you shouldn’t hesitate to build you case. In addition to gathering evidence and understanding your policy, you have to know how to navigate the claims and appellate processes. Fortunately, you can take the guesswork out of them by educating and preparing yourself as much as possible before moving forward. Help is out there to assist you with that preparation if you need it.
]]>On Behalf of Mansell & Engelhttps://www.theinsuranceattorneys.com/?p=493602023-10-02T16:43:48Z2023-10-02T16:43:48Zoutright denies claims that should otherwise be paid. Therefore, as you enter the claims process, you need to know how to navigate it as effectively as possible. This includes avoiding devastating mistakes that could cost you your claim.
Common mistakes when dealing with homeowner’s insurance
Although we wish the insurance policy was simple, it isn’t. To make it as smooth as possible and increase your chances of recovering the financial resources you need, though, you have to avoid making errors. Here are some of the most common that you’ll want to be on the lookout for:
Inadequately documenting property damage: When your home is damaged, you need to take detailed photographs of the damage, write a description of the damage, and record the cost to repair it. If you don’t, then you might be cut short on your claim.
Repairing the home too quickly: In the aftermath of the event that left your home damaged, you might be tempted to fix the damage as quickly as possible. However doing so can make it hard for the insurance adjuster or engineer to see the true extent of the damage that was caused. So, while you might need to make some temporary repairs to restore functionality, avoid permanent repairs until after the insurance company has visited you.
Getting rid of damaged property: If you throw out damaged property that’s covered by your insurance policy, then it’s going to be hard for you to argue that you should be compensated for those losses. Therefore, keep all damaged property until your claim is resolved.
Not tracking additional living expenses: The damage caused to your home might require you to stay at a hotel and accumulate other costs that you otherwise wouldn’t have to endure. These expenses might be compensable under your insurance policy, but your provider is going to be hesitant to fork over payment for them if you can’t prove that those costs were incurred.
Not knowing your policy: Before you head into any negotiations with your insurance company, you have to know the details of your insurance coverage. Only then will you know where you can push to get what you deserve?
Accepting a low settlement offer: Insurance companies want to protect their profits, which is why they try to settle claims for less than they’re worth. Although you might be eager to get cash on hand, repair your home, and move on with your life, make sure you’re not taking a settlement that leaves you with less than you deserve.
Don’t derail your insurance claim
The insurance claims process is complicated. As a result, thorough preparation is your best bet to building the solid claim that you need to succeed. While this includes submitting a sound claim, it also means knowing the law and how to avoid common mistakes that destroy your ability to recover the compensation you need. That’s why many homeowners seek out legal assistance when handling these matters.
If you want to know more about the insurance claims process and some of the issues that can arise, then please continue to read our blog and browse our website.]]>On Behalf of Mansell & Engelhttps://www.theinsuranceattorneys.com/?p=492432023-10-25T15:19:33Z2023-09-07T14:47:39Zseveral common risks and liabilities that the business may encounter. These include property damage and personal injury in addition to others.
Coverage overview
There are several types of incidents CGL may cover. If a person is injured on the premises, the policy may cover medical expenses, legal fees and other damages. It may also cover the cost of repairs or replacement of someone else’s property that is damaged by the business.
If a person brings a claim against the business for a non-physical injury, like libel, slander, defamation or a copyright violation, the CGL policy may cover that. It may also protect the business from claims of injuries from defective products. Sometimes, the policyholder may also be entitled to reimbursement for legal fees and court costs.
These are only some examples of coverage, and many policies have specific exclusions.
Addressing denials
If a business owner makes a claim under their CGL policy and it is denied, they should receive a denial letter. It’s helpful to review the denial letter and the insurance policy to understand whether the claim is excluded under the policy.
If the business owner has photos, witness statements, contracts, invoices or other evidence to support the claim, it’s helpful to gather those as well. They can support the reasons for the claim, especially if it is appealed through the insurance company’s appeals process.
If the dispute cannot be resolved with the insurance company directly, the business owner may file a complaint with the state insurance regulator or pursue legal action. There is assistance available.]]>On Behalf of Mansell & Engelhttps://www.theinsuranceattorneys.com/?p=491982023-10-25T15:19:47Z2023-08-23T17:12:32ZAccording to the Oklahoma Insurance Department, wildfires routinely destroy hundreds of structures every year resulting in millions of dollars in damages to property. But, does commercial property insurance cover wildfire damage?
The answer, as with most legal questions is, “It depends.”
All-risk policies
There are types of commercial property insurance policies that offer different levels of coverage for wildfire damage. One common type is all-risk policies. These policies cover all causes of loss, except those that are specifically excluded.
Wildfires are usually not excluded, unless your property is located in a high-risk area. However, some all-risk policies may have limits or deductibles for wildfire damage, which means you will have to pay more out of pocket before your insurance kicks in.
These are policies offered by the Fair Access to Insurance Requirements Plan Association, a state-run program that provides basic fire insurance to property owners who cannot obtain coverage from the standard market.
The FAIR Plan Commercial Fire Policy only covers fire, lightning and internal explosion. It does not cover other perils, such as smoke, water or wind damage.
Review your policy
If you have questions, ask your agent or company for clarification. You should also know what your deductible and policy limits are, and how they affect your claim. The time to add coverage is now, before you need it.]]>On Behalf of Mansell & Engelhttps://www.theinsuranceattorneys.com/?p=491972023-10-25T15:19:55Z2023-08-09T20:11:23Zdepends on the type of health insurance you are seeking and your health status.
Oklahoma law
According to the Oklahoma Insurance Department, there are three main types of health insurance: traditional health insurance, managed care services and limited benefits insurance.
Traditional health insurance, also known as fee-for-service, allows you to use any doctor or hospital and submit your bills to the insurance company. However, this type of plan is rare and mostly found in grandfathered plans that are not compliant with the Affordable Care Act or in Medicare Supplement Plans. Most ACA-compliant plans are comprehensive medical policies that pay a percentage of covered expenses after you pay a deductible and copays.
Managed care
Managed care services are plans that contract with a network of providers to offer health care services at lower costs. These include Health Maintenance Organizations, Preferred Provider Organizations, Exclusive Provider Organizations and Point of Service plans.
With these plans, you may have to choose a primary care provider who coordinates your care and refers you to specialists when needed. You may also have to pay more or get prior authorization if you use out-of-network providers.
Limited benefits
Limited benefits are plans that only cover certain types of services or have low benefit limits. These include short-term health plans, fixed indemnity plans, accident-only plans and critical illness plans. These plans are not regulated by the ACA and do not have to cover essential health benefits or pre-existing conditions.
Doctor examination
So, do you need to be examined by a doctor for any of these types of health insurance? The answer is no, if you are enrolling in an ACA-compliant plan or a government plan such as SoonerCare (Oklahoma Medicaid), Medicare or VA.
These plans do not require medical exams or ask about your health history when you apply. They also cannot deny you coverage or charge you more based on your health status.
However, the answer may be yes, if you are applying for a non-ACA-compliant plan, such as a short-term health plan or a fixed indemnity plan. These plans may require you to answer health questions or undergo a medical exam before they accept you. They may also exclude or limit coverage for pre-existing conditions or charge you higher premiums based on your health status.]]>On Behalf of Mansell & Engelhttps://www.theinsuranceattorneys.com/?p=491942023-10-25T15:19:56Z2023-08-04T17:47:43Zfile an internal appeal.
If you file the internal appeal and you are still not satisfied with the outcome or if your insurance carrier waives your appeal, there is recourse. The recourse is that you (or an authorized representative for you) can request that the Independent Review Organization, or IRO, review the decision. That would be considered an external review.
What exactly is an external review?
An external review is a review by a person or entity that has absolutely nothing to do with your insurance company or your particular insurance policy. Before you are granted an external review; however, you will need to qualify for that type of review. Subsequently, the IRO will assign you a reviewer at random.
External reviews are carried out by IROs. The IROs must be certified by the Oklahoma Insurance Department, or OID, as well as holding national certification. The criteria for being certified is that the examiner must prove that they are unbiased and that they have a process to guarantee that their examiners are fully qualified and independent.
Which disputes are eligible for examination and which are not?
Some disputes qualify to go through external review and others don't. The criteria for eligibility are based on medical necessity, health care setting, appropriateness and care level or effectiveness. This includes denials because a treatment is investigational or experimental.
If your claim involves a treatment that is not covered by your insurance. Additionally, if you carry government insurance (such as Medicare, Medicaid, or some other government plan), you won't meet the eligibility requirements for an external review. When you receive the denial from your insurance, you will also receive information on your rights for appeal. You will also be informed at the same time about asking for an external review.
Once you have filed an internal appeal and it was denied, you can apply for an external review to the OID. You will have four months from the date of the final decision to request the external review. If the result of your external appeal is positive, your insurance company is obligated to abide by the decision.
You have rights and you need to protect them
If you have been unjustly denied based on the claim that you submitted to your insurance company, that is not legal. You have rights that need to be protected and you have a right to receive compensation from your insurance company for damages. It is a really good idea to educate yourself about what you are entitled to and what you deserve to have. The fact is that you have been paying into your insurance to ensure that you are covered. You are not asking for something for free. You are asking for what you are entitled to have if you need it.]]>On Behalf of Mansell & Engelhttps://www.theinsuranceattorneys.com/?p=491962023-10-25T15:20:15Z2023-07-31T07:53:44ZCar and health insurance
Car, health and property insurance are the 3 main types of insurance most people have. When it comes to car insurance, Oklahoma requires $25,000 of bodily injury and property damage protection and $50,000 of coverage per accident.
As you probably know, most Oklahoma residents are now required by federal law to have some type of health insurance policy. You may have an insurance policy through your employer, but if you do not, you can get your own insurance plan through the Affordable Care Act.
There are minimum coverage requirements with health insurance, as well. Your specific minimum requirements are going to depend on the type of plan you select, but they must adhere to both federal and Oklahoma state law.
Property insurance
Oklahoma law does not require you to have property insurance, but you may be required to have it as part of your financing when purchasing a home. A property insurance policy is also a good idea in a state like Oklahoma, where tornadoes are relatively common.
Some basic property insurance coverage includes dwelling coverage, which covers damage to your home and attached structures or additional coverage for structures not attached to your home. You can also choose to obtain coverage for personal possessions or living expenses if you are displaced from your home.
Why should I know these requirements?
Knowing the insurance requirements and details of any policies you have is important in case you file an insurance claim that is denied.
There are various reasons why insurance claims may be denied. Sometimes it is a simple reason. You may have submitted incomplete or inaccurate information or forgotten to submit a document.
An insurance representative will typically contact you and tell you what information or documents you must still provide for them to evaluate your claim.
Insurance claims can also be denied because the claim has errors. These errors can be simple data errors that must be investigated and corrected.
Disputing a denied insurance claim
However, sometimes claims are denied because there is a dispute over fault or liability. If you were in a car accident, the insurance company may believe you were to blame, or your health insurance claim could be denied because the insurance company believes your health issue was avoidable.
Property insurance claims could be denied because you do not have enough evidence to back up your claim. Evidence for a property insurance claim is usually documents or receipts showing you own the home and sustained certain damage.
An insurance dispute can quickly become confusing and complex. There are professionals who can help you understand how to dispute a denied claim and what you must show to have your claim approved.
]]>On Behalf of Mansell & Engelhttps://www.theinsuranceattorneys.com/?p=491932023-10-25T15:20:34Z2023-07-26T15:43:53Zprotections that prevent surprise medical bills for most emergency and some non-emergency services, regardless of whether you have a group health plan, Health Insurance Marketplace plan or an individual health insurance plan.
An example
For example, you may have gone to an in-network hospital for emergency care, but received services from an out-of-network doctor, anesthesiologist or radiologist who works there. Or, you may have scheduled a surgery at an in-network facility, but found out later that the lab tests, imaging or other services were performed by out-of-network providers.
No more surprise billing
The prohibition on surprise medical billing was part of the No Surprises Act, which was enacted on December 27, 2020, as part of the Consolidated Appropriations Act of 2021. Now, you cannot be charged more than in-network cost-sharing (like coinsurance or copayments) for emergency services, even if you get them from an out-of-network provider or facility and without prior authorization.
In-network cost limits
You cannot be charged more than in-network cost-sharing for non-emergency services from out-of-network providers at in-network facilities, unless you receive a notice and consent to waive the billing protections at least 72 hours before the service. This does not apply to certain additional services (like anesthesiology or radiology) that are furnished by out-of-network providers as part of your visit to an in-network facility.
What are my options?
If you live in Oklahoma City, Oklahoma, and you receive a surprise medical bill from a health care provider or facility after January 1, 2022, you have options. Check your advanced explanation of benefits and compare it with your bill. Make sure that you are not being charged more than in-network cost-sharing for any services. If you believe that you have been billed in violation of the No Surprises Act, contact the provider or facility and ask them to correct the bill. You can also file a complaint with the Oklahoma Insurance Department or the U.S. Department of Health and Human Services.
If you are not satisfied with the response from the provider, or if you disagree with what your health plan paid, you can request an independent dispute resolution process through your health plan or the provider. You will need to provide evidence to support your claim, such as your advanced explanation of benefits, your bill, etc.]]>On Behalf of Mansell & Engelhttps://www.theinsuranceattorneys.com/?p=491922023-10-25T15:20:46Z2023-07-12T16:12:36ZDoes liability coverage take care of hit-and-run drivers?
Liability insurance is the minimum insurance required by Oklahoma state law. Strict liability coverage typically will not cover a hit-and-run car accident as it is only intended to cover potential damage to the other driver or another’s property, not your own.
You do have other potential insurance types to consider if you are seeking protection from a hit-and-run driver.
UM/UIM and collision coverage
Uninsured motorist and underinsured motorist coverage is sometimes used for hit-and-run accidents. This coverage is also useful when the driver is known, but they do not carry the minimum liability coverage or the coverage they do have will not cover your damages.
Minimum liability coverage is often not enough to cover severe injuries or damages.
Collision coverage is also used for hit-and-run accidents
It is a good idea to examine your auto insurance policy to check if you have insurance coverage in case of a hit-and-run accident. Insurance companies may even attempt to deny claims when you do have the coverage for hit-and-run crashes.
Insurance companies accept premiums in exchange for providing you coverage, and you have options to appeal any denials. If you do not carry either of these coverages, it is possible that you will be left to bear the financial burden of another driver’s negligence.]]>