Health Care Plan Disputes

Health care plans provide consumers with medical care packages as well as insurance plans. There are numerous different types of health care plans, also referred to as health insurance or simply, health care.

For example, a health care plan may be obtained through a private health plan company, through coverage that is provided by an employer, or through a government assistance program. Although health care plans can be helpful, they can also be a common source of disputes that result in numerous lawsuits being filed each year.

What Are Health Insurance Plans?

A health insurance plan is insurance coverage that covers the insured policyholder from paying certain medical and surgical expenses. Health insurance plans with health insurance benefits are often necessary because individuals who do not have them may be required to pay substantial out-of-pocket expenses in a medical emergency.

Health insurance can pay a portion of the cost of medical emergencies that are associated with an individual’s vision, dental, or other medical needs. Depending on the individual’s health coverage, these costs can be paid in one of two ways, including:

• The individual pays up front out of their own pocket and is then reimbursed for the cost; or
• The insurance company pays the individual’s provider directly.

If an individual has health insurance coverage, they have to pay the insurance company a premium in exchange for the insurance company paying their medical bills. The cost of the insurance premiums vary depending on the coverage plan the individual has.

What Are Some Common Health Care Plan Disputes?

Health care plan disputes can involve many different factors. Common examples of health care plan disputes include:

• Denial of medical coverage for benefits or services;
• Refusal to authorize the insured individual’s medical procedure or hospital visit;
• Incorrect charges for medical services;
• Cancellation of health insurance policies without providing notice; and
• Refusal to carry over a policy when changing jobs.

A dispute over health care coverage or a policy can involve many different parties, including:

• The insured;
• The policy provider;
• The employer;
• A medical company; and
• Other parties.

The majority of health care plan disputes, however, involve a direct claim between the insured and the policy provider. If an individual has any questions or issues with their health care plan, they should consult with a health care lawyer.

How Does Obamacare Factor Into This?

The federal government passed the Affordable Care Act, also called Obamacare, in 2010. Obamacare is a health insurance reform bill that adds several layers of new rules to insurance laws that are already complex.

The major changes Obamacare made to health care plan laws include:

• Making it illegal for insurance companies to deny services based on pre-existing conditions;
• Creating a list of benefits that an insurance company must provide as part of their health care plans, including birth control;
• Forcing employers with a certain number of employees to provide health care insurance;
• Creating minimum standards for out-of-pocket payments; and
• Permitting children to stay on the health care plan of their parents until they turn 26.

How Do I Resolve the Disputes on My Health Care Plan?

If an individual is involved in a dispute regarding their health care plan, there are steps that they can take to help remedy their situation. An individual can file a claim for a health care plan dispute in several ways, including:

• Obtain notice: If an individual was denied coverage or had their policy canceled, it is important to get the denial or cancellation and the reasons for it in writing. There are two reasons for this:
  • First, there are laws which require that insurance companies provide notice before denying services, so this can buy an individual some time;
  • Second, it will be easier to review the decision in or out of court if an individual has paperwork detailing the insurance company’s reasoning;
• Internal review: An internal review is essentially a claim that is filed through the complaining processes of the health care organization itself. An outside agency is used for resolving the complaint;
  • This is also referred to as a consumer complaint, in which a healthcare company provides the insured with a remedy for their losses;
• External review: This is where an outside agency reviews an individual’s complaint. An external review may be necessary in cases where an internal review cannot fully resolve the dispute;
  • However, external reviews are not always available for every claim. They are usually reserved for individuals who are self-insured or who are insured through an employer-sponsorship program;
• Arbitration or mediation: It is not unusual for an insurance contract to contain a clause similar to, “any disputes will be submitted to arbitration” or “any dispute will be mediated before litigation,” which will require alternative dispute resolution;
  • In general, an insurance holder does not want their claim to go to arbitration because the insurance companies have pre-chosen the arbitrator with no means of appeal;
  • Mediation is fairer to an individual because the mediator has no legal power. However, meditation can also be used simply as a means to delay trial; and
• Civil lawsuit: If the parties are not able to reach an agreement through an internal or external review, it may be possible to file a lawsuit in a civil court. This will involve presentation of evidence and may require the testimony of expert witnesses;
  • In severe cases, a lawsuit can be filed before a review is filed.

Whether an individual plans to resolve their dispute using a review, arbitration, mediation, or a lawsuit, an individual will need to ensure they are thoroughly prepared to argue their claim. It is most important for an individual to understand their health care policy before they try to file a claim.

They may want to highlight or underline the terms they believe were violated as well as gather any supporting documentation.

What Are Other Remedies if an Internal Review is Unsuccessful?

If an internal review is not successful, an individual may be able to pursue other remedies, such as an external review. External reviews occur when agencies outside of the insurance provider review an individual’s complaint.

It is important to note that an external review is typically available for an individual who is self-insured or who is insured through an employer-sponsorship program. An individual’s insurance contract may include a mediation or an arbitration clause.

These clauses require that an individual resolve their dispute using either an attempt at reaching a resolution through mediation or by binding arbitration before filing a civil lawsuit. If an individual’s insurance plan does not include a mediation or an arbitration clause, or if the mediation does not successfully resolve the dispute, an individual may file a lawsuit in civil court.

Civil lawsuits require evidence to be presented to a jury of the individual’s peers, including testimony and expert witness testimony.

What If My Plan Was Canceled Because of Obamacare?

There are thousands of Americans who will receive a notice or who have received a notice that their healthcare plan is being canceled. This may be because it fails to comply with the essential benefits provision or because it does not comply with the minimum out-of-pocket expense provision.

In either of these situations, President Obama has signed an executive order extending the deadline for insurance companies to comply with those provisions of the Affordable Care Act.

Do I Need a Lawyer for Help with a Health Care Plan Dispute?

If you have a health care plan dispute, it is important to consult with a health care lawyer. Your lawyer will be able to review your policy and advise you of the laws in your state.

Your attorney will understand the various factors that are involved in health care plans. They will also help you obtain legal relief for losses you have suffered related to your dispute.