Anthem Blue Cross of California Medical Necessity Denial Lawyer

Facing a serious medical diagnosis or the possibility of one can be quite stressful and can cause a lot of uncertainty. At a time when you need to be able to rely on your health insurance company to do their part in honoring their contract with you, they may decide to deny a test, treatment, or medication that your own physician believes to be medically necessary for you.

Many times when this happens, patients do not have the resources to pay for their medical needs out of their own pocket—nor should they have to when their insurance company should be covering it. An Anthem Blue Cross of California medical necessity denial lawyer may be able to help you if you were denied coverage for a medically necessary test or treatment.

Who Decides Medical Necessities?

As to be expected, physician’s opinions of claims that are medically necessary can be quite different than that of health insurance carriers. Physicians want to see their patients get the best care available, while insurance companies are watching their bottom line.

Insurers in Los Angeles are duty-bound to consider both the interests of the people it insures as well as their own financial interests. Despite this, many companies still look primarily at the price tag associated with medical procedures instead of recognizing research and medical opinions.

Policy Interpretations

Often a main point of contention in cases against insurers is whether the insurance company is acting as they should be based on their contract with the policy holder and whether they are acting reasonably. Oftentimes, payment for medically necessary claims gets caught up in the interpretation of the insurance contract or an examination of why and/or how the insurer made its determinations on coverage.

However, it is important to determine what the insured party could have reasonably expected their policy to cover. If a policy’s specific language is unclear, this determination would decide how the policy is ultimately interpreted. If no such expectation can be identified, the policy will be interpreted in a way that favors the position of the policyholder.

Subscriber Rights

Per federal and California state laws, health insurance companies must have a process set up for denied claims to be appealed. This process can vary whether a health insurance policy is governed by ERISA, a federal law regulating most group plans, or California law, which governs most individual and some group plans. Once the insured party receives notice of denial, they have 60 days to file such an appeal.

Regardless of whether the appeal is granted or denied, they may be able to seek a second appeal with a third-party, or they can hire a medical necessity denial lawyer in Los Angeles to help with their Anthem Blue Cross claim if they have a non-ERISA policy. Otherwise, the insured would need to wait for a denial before the option of litigation is available. Regardless, it can be helpful to contact an attorney immediately after receiving a denial to help determine the next best course of action.

Seek a Medical Necessity Denial Attorney’s Help with Anthem Blue Cross of California

You have enough to worry about when you are facing medical issues—wondering if your insurance company will pay for your claim should not be one of those worries. Contacting an Anthem Blue Cross of California medical necessity denial lawyer may shed new light on your case and your rights, and it could potentially result in your health insurance carrier paying your claim that they once rejected.

Call today for legal assistance with your health insurance difficulties. Our attorneys are experienced in handling claims against Anthem Blue Cross of California and are prepared to represent you.