Fighting Back: Appealing Insurance Companies Denying Coverage For Recommended Treatments

This article dives into the disheartening denials of recommended medical treatments by insurance companies and provides guidance on fighting back. You will learn:

• When a recommendation denial by an insurance company can be appealed,
• The rights and consequences surrounding insurance company denials, and
• How to improve your case, avoid denials, and improve appeal chances.

Can An Injured Worker Appeal An Insurance Company’s Denial Of Coverage For Recommended Medical Treatments?

When an insurance company decides to deny or delay coverage for treatments medically recommended by your doctor after a workplace injury, you can, with the help of a competent patient advocate attorney, appeal these decisions.

If an insurance company is not being reasonable in providing medical treatment, or your medical treatment is not being honored or respected, they might be acting unlawfully. In those cases, you can ask for a hearing or your patient advocate attorney can pursue the case with the insurance company directly.

Sometimes an Independent Medical Examination (IME) or other reviews of your doctor’s decisions fall outside the bounds of the Workers’ Comp Act. They are not lawful, which can be grounds to appeal or threaten to request a hearing and ask for sanctions from the industrial commission if it looks like the insurance company is not being reasonable or is not following the law.

We would all like to think that the health of the injured workers is still the most important thing in the system. Unfortunately, when we see some of the decisions being made sometimes, it is hard to be sure. Nevertheless, there are ways to challenge any medical decision that an insurance company makes.

In some cases, this can be an opportunity for you to get a second opinion and use that information to challenge the insurance company’s decision to deny any kind of medical treatment.

What Are The Consequences For An Insurance Company Denying Coverage For Recommended Medical Treatments?

Unfortunately, the consequences for denied medical coverage or treatment are incredibly one-sided, falling almost exclusively on the injured worker.

Indeed, there are simply not a lot of consequences to the insurance company when they deny medical treatment. Insurance companies are allowed to deny claims with impunity, as they are rarely held accountable by the industrial commission. In stark contrast, the consequences to injured workers can be massive.

You might go for months without getting the treatment(s) you need, which could lead to your condition getting worse. In addition, you might not be getting the pain treatment or pain medications you need and struggle to adapt to the situation as a result. And that is only one side of the equation.

Denied medical treatments can even mean that an injured worker loses their job in the long run. Employers cannot hold jobs open forever, even if they wanted to and they rarely do. If medical treatment or disability drags on for a long time, you might not be able to keep your job. Alternatively, you might be expected to change jobs or leave the job entirely even if you are able to return to the same kind of work in the future because of untreated injuries.

What Rights Do Injured Workers Have When Their Insurance Company Denies Coverage For Medical Recommendations?

While the odds are stacked in favor of the insurance companies, when they deny you coverage for medical recommendations, you have the right to contest it.

The most important right is your ability to request a hearing before the industrial commission. If the insurance company is just not doing the right thing and you are confident that the doctor’s recommendations should be allowed, paid for, and authorized by the insurance company, you don’t have to walk away or throw your hands up.

You can request a hearing in front of a deputy commissioner at the industrial commission and make a case for why the industrial commission should order the insurance company to pay for the medical treatment being recommended. You can file a motion with the help of a strong attorney and make the argument that the medical treatments should be provided based on what your medical records and documents show.

If these claims are accepted, the insurance company will have to have a good reason why they are not authorizing the medical treatment. If their reason is vague, unsubstantiated, undescribed, or unarticulated it will not be looked upon well by the industrial commission.

Thus, you do always have a chance to make the Industrial Commission review everything and demand a fair argument be presented. You can bet the insurance company will do everything in its power to tear down your case, including diving deep into your medical records.

How Can I Ensure My Medical History And Current Health Status Are Accurately Reflected In Insurance Company Records?

Insurance companies will often try to use your medical records against you to try to deny coverage for recommended treatments. Often, they can do so because medical records are not clear or histories are not taken down with specifics, which can leave you vulnerable.

One option to improve your chances is to have an attorney review past relevant medical records. They can try to make sure nothing is too inconsistent in those records, and find anything that would hurt your chances of getting recommendations approved and authorized medically.

The other thing that you can do is actually write out your complaints and document them. When you go see the doctor, provide a written account of your issues and conditions and ask that document be included as part of your medical records.

Obviously, when an intake nurse takes notes about your history and then transcribes them later on into the medical record, there are many opportunities for even just small differences to appear. Even the smallest discrepancy between what you are saying versus what has been written down is something an insurance company will not hesitate to take advantage of.

But when the medical record itself is your own handwriting or is a signed, typed-out statement that includes all the details and specifics of your condition, there is much less chance there is going to be a mistake made. This can help improve your chances dramatically in a later appeal. Your medical history and the description of your conditions will be consistent with what you say you have experienced.

For more information on Appealing An Insurance Company’s Denial Of A Claim, a free initial consultation is your next best step. Get the information and legal answers you are seeking by calling (833)444-4127 today.