If You Paid For Health Insurance, You Deserve To Benefit From It

If your doctor is recommending that you undergo a certain course of treatment, yet your insurance company is refusing to cover the cost of that treatment, turn to Mansell & Engel in Oklahoma. We are highly skilled at taking even the largest insurance companies to court over their refusal to pay policyholders what they deserve.

Our lawyers have a stellar reputation for resolving “bad faith” lawsuits all over Oklahoma and beyond. Our attorneys have also earned an AV Preeminent* peer-review rating through Martindale-Hubbell, which testifies to our integrity and skill.

Often, An Insurance Carrier Will Say Treatment Isn’t ‘Medically Necessary’

An insurance company often bases a claim denial on the medical opinion of one of its in-house doctors. This doctor probably never examined you. He or she likely looked at your medical records and made a determination about the medical necessity of your condition from a biased position without full knowledge of your condition.

This is not the same as evaluating the necessity of treatment based on your actual condition, which may have unique aspects to it. Your personal, treating physician – not the insurance company’s physician – is in the best position to make a true assessment.

Our law firm will work with your treating physician to gain a full and accurate picture of your medical needs. Then we will go to battle on your behalf, vigorously pursuing the health insurance benefits that you deserve to cover your medical bills.

Disputes Over The ‘Usual And Customary’ Charge For Medical Care

Another common tactic is for insurance companies to reduce benefit payments based on the “usual and customary” charge for a certain medical service. Essentially, the company claims that your medical provider should have charged less, and therefore it underpays your health insurance claim.

Most of these “usual and customary” denials occur on a routine basis and affect numerous policyholders at the same time. You are probably not the only one facing reduced payments. It’s likely that thousands of other people are also being cheated. By standing up for your rights, we can help bring about justice for many others as well. This is our mission at Mansell & Engel.

Other Excuses For Denying Your Claim

Insurance companies may claim the following to keep you from getting your money:

• Medical treatment is not covered, authorized or necessary or is experimental
• Your medical treatment was out of network
• The medical procedure is purely cosmetic
• You allegedly misrepresented something in your original application
• Your insurer never received proper paperwork
• Your insurer is waiting for a third-party evaluation
• Your insurer offered to pay for a less expensive treatment/procedure

You do not have to simply take “no” as an answer. An experienced insurance claims attorney can help you overcome a denial in many cases.

What Can I Do If My Health Insurance Claim Is Rejected?

If your claim was denied, first, don’t give up. Instead, do some digging and get an advocate on your side. If possible, get copies of your health insurance policy and bank statements, pay stubs, canceled checks or other proof that you paid premiums on time. Ask your doctor’s office staff for copies of medical records showing your doctor’s recommendations.

With some documentation to back up your claim for coverage, you can work with a knowledgeable lawyer to discover the key to turning a denial into approval for benefits that you are eligible for.

At Mansell & Engel, we have helped many clients turn things around when they faced denied Aetna health insurance claims, Sierra Life & Health insurance claims and denials from many other insurers.

Frequently Asked Questions About Health Insurance

At Mansell & Engel, our attorneys will answer any questions you have about the insurance industry. Some frequently asked questions include:

What is the difference between HMO, PPO, EPO and POS plans?

HMO, PPO, EPO and POS plans provide different forms of medical care. The differences between each of these plans are explained below:

• Health Maintenance Organization (HMO): Provides medical coverage for in-network health care providers, except for emergencies. A primary physician referral may be needed to see a specialist.
• Preferred Provider Organization (PPO): Provides discounts for in-network health care providers and some out-of-network care. Typically, patients can see a specialist without a referral.
• Exclusive Provider Organization (EPO): Provides coverage for in-network care, with the exception of emergencies and usually does not require a referral for a specialist.
• Point of Service (POS): Covers some out-of-network and in-network care and often requires a referral to obtain a specialist’s services.

Although all these plans include networks of medical providers, only some cover nonemergency care, while others offer partial coverage for both in-network and out-of-network services.

What are copayment and coinsurance?

Medical care may require a copay, which is an out-of-pocket cost to receive services and may not count toward insurance deductibles.

Coinsurance is a percentage of the cost of medical services that apply after a deductible is met. The cost of coinsurance is paid out-of-pocket until you have reached your maximum out-of-pocket limit.

What does ‘out-of-pocket maximum’ mean?

An out-of-pocket maximum is how much you may need to pay for medical coverage before your insurance covers the entirety of medical services.

How can I find out if my medications are covered?

Insurance companies often have several ways for people to learn what kind of medications are covered. You may be able to reach out by phone or find information online about prescriptions your insurer covers.

What happens if I miss a premium payment?

Falling behind on a premium payment could lead to the insurer ending your coverage. However, there is often a grace period allowing you to pay after the due date without facing problems.

We Are Ready To Fight For You

No matter which excuse you received or which insurer denied your claim, call Mansell & Engel for a free case evaluation: 405-212-5921. You can also reach our Oklahoma City office via email.

*AV Preeminent and BV Distinguished are certification marks of Reed Elsevier Properties Inc., used in accordance with the Martindale-Hubbell certification procedures, standards and policies. Martindale-Hubbell is the facilitator of a peer review rating process. Ratings reflect the confidential opinions of members of the Bar and the judiciary. Martindale-Hubbell ratings fall into two categories – legal ability and general ethical standards.