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What to Do When an Insurance Claim Is Denied

Posted in on May 27, 2016

When you have health insurance, you expect the insurance company to pay your claims. You need the insurance company to cover your medical care both promptly and fairly. If the insurance company denies your claim, you have options and may want to work with a Colorado bad faith insurance lawyer. Here’s what to do if your health insurance claim is denied.

How to Fight Insurance Claim Denial

To fight an insurance claim denial, there are several steps you can take. First, you can request an internal review. Representatives of the insurance company should review the claim again. If they still deny your claim, you can request a third-party review. Finally, you can bring a claim in a court of law based on an unfair insurance claim denial.

Insurance Claim Denied

What Can I Do If My Insurance Company Denied My Claim in Colorado?

If your insurance company denies your claim, you can request a review of the decision. Usually, there’s information in the denial letter about how to appeal. Once you exhaust internal reviews, you can request an external review by the Colorado Division of Insurance. In addition, you have the right to bring a court case to a Colorado court. You can ask the court to order the insurance company to pay your claim and pay an additional amount to cover your attorney fees and court costs.

Reasons a Health Insurance Claim Might Be Denied

Here are some reasons that a health insurance claim might be denied:

  1. Not covered by the policy – Different insurance policies have different kinds of coverage. Check to see that your procedure or care is covered at the amounts that you’re expecting.
  2. Referral required – Some health insurance policies require you to have a referral from your general care physician. If you don’t have the necessary referral, the insurance company may deny your claim.
  3. Clerical errors – If your medical care provider submits your claim with a typographical error, or if you give bad insurance information to your care provider, your claim might be denied. When you receive a claim denial, be sure to check all of the basic information for errors.
  4. Out of network – Your insurance policy may require you to choose from a network of providers. If you go outside the network, the insurance company may deny your claim or pay you at a different rate than if you had gone in network.
  5. Bad faith – When an insurance company denies your claim without a good reason, it’s called acting in bad faith. Sometimes, insurance companies deny good claims because they use bad faith practices.

How Do I Fight Health Insurance Claim Denial?

You fight a health insurance claim denial by taking advantage of all of the opportunities to appeal the decision. Pay attention to deadlines to file internal appeals. You can request an external review if you’re unhappy with the insurance company’s appeals. Finally, you may file a lawsuit against the insurance company if they refuse to honor their policy. You have the right to representation from the attorney of your choice.

How to Fight Insurance Claim Denial in Colorado

Fighting an insurance claim denial begins with internal reviews. Usually, your denial letter has information in it about how to appeal a decision. It typically means writing a letter or filling out an appeal form. The insurance company will have a new representative review the claim. That person shouldn’t have been a part of the original decision. There may be one or two rounds of internal appeals.

Once you exhaust your internal appeals, you move to an external review. You can file a complaint with the Colorado Division of Insurance Consumer Complaint Portal. The Department of Regulatory Affairs will refer the matter to an expert to review the claim.

After all administrative reviews, you can bring a lawsuit in court. In Colorado, you can file your claim based on both common law and Colorado’s bad faith insurance statute. You can ask for up to double the amount of the covered benefit as well as attorney fees and court costs. The jury makes the ultimate decision about whether the insurance company denied your claim in bad faith.

Colorado Bad Faith Claim for Health Insurance Denial

The State of Colorado allows two different types of lawsuits for bad faith insurance denials. If the insurance company denies your claim in bad faith, you can file your claim under both sets of laws. First, is Colorado’s written laws for bad faith insurance denial. Colorado Revised Statutes 10-3-1115 and 10-3-1116 are Colorado’s bad faith insurance laws.

Colorado’s bad faith insurance laws say that an insurance company may not deny payment without a reasonable basis. The law states that a victim of an unreasonable insurance denial may demand twice the denied benefit as well as the costs of litigation. Colorado’s written laws for bad faith insurance makes it clear that common law remedies still apply.

Colorado’s common law bad faith insurance laws say that bad faith occurs when the insurance company acts unreasonably and with reckless disregard for honoring the insurance policy. The insurance company operates in bad faith when they have no reasonable basis for denying the claim. Even though the common law is slightly different than the written law, they’re both important and helpful ways for victims of bad faith insurance to get the justice that they deserve.

Example of Fighting an Insurance Denial in Colorado

In the 2018 Schultz v. GEICO Casualty Co., the Colorado court made it clear that common law and statutory law apply in bad faith insurance claim denials. The Schultz court made it clear that the jury must evaluate the insurance company’s conduct based on the evidence that the insurance company has before they make the coverage decision. The insurance company may not create new evidence to defend its decision after the fact.

Contact Our Denver Attorneys for Bad Faith Insurance Denials

Has an insurance company denied your claim? Did they deny your claim in bad faith? You have rights.

Our Denver bad faith insurance lawyers can help you fight the insurance company. We’ve helped thousands of people just like you. When you work with us, we fight until you have the justice that you deserve. Contact us today at (303) 222-2222 for a free consultation about your claim.

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Super Lawyers - Kyle Bachus
Super Lawyers - Darin Schanker
Million Dollar Advocates Forum
The National Trial Lawyers Top 100 Trial Lawyer
5280 Top Lawyers of Denver
Martindale-Hubbell Peer Rated for Highest Level of Professional Excellence