Claim Editing: One Reason Why Insurance Company Disputes Are All Too Common

Hayward Insurance Bad Faith Lawyers

When you submit a claim for insurance benefits, you expect your insurance company to treat you fairly and honor its end of the policy, unfortunately, it is not uncommon for insurance carriers to devalue or deny a claim without proper investigation or consideration. However, just because an insurance company does something, does not mean it is legal and that you have to accept a wrongfully denied insurance claim as the final word.

According to the National Health Insurer Report Card (NHIRC), in 2013, Anthem was the leader in the number of denied claims, denying roughly 2.6% claims received. In 2012, Anthem reported denying 5.07% of all claims. Humana denied almost two percent of claims in 2013. That may not sound like a lot, but these numbers only reflect claims denied for reasons other than a claim edit (if denials based on a claim edited by the insurer were included, these rates would be even higher. ) reported on the practice of using automated technology to increase the number of denied claims using claim editing:

…They [insurance companies] use auditing software, often called “claim review programs” to sift through millions of submitted claims. Others have dubbed this software “denial engines” because their intent is to lower the amount of money paid to physicians and hospitals. These auditing programs work by finding technical errors in billing codes that all doctors, hospitals and clinics, among others, submit for payment. The programs use data-mining technology and can even be tuned to capture a predetermined percentage of financial return.

California has laws specifically designed to protect you from your insurance company wrongfully denying or under paying on a claim, and provides for legal remedy if an insurance company does violate the law. By filing a bad faith lawsuit, we can attempt to recover damages outside your benefits coverage. These damages can include attorneys’ fees and emotional distress.

As an experienced insurance bad faith law firm, Donahue & Horrow LLP, has more than five decades of experience providing legal advice and representation to California clients. If you have filed claims for disability insurance, long-term care insurance or health insurance, you run the risk of having your initial benefits claim denied. If your insurance carrier denies your claim without proper consideration, we might be able to recover compensation through an insurance bad faith lawsuit. Schedule a free consultation at your earliest possible convenience.

Insurance Bad Faith – Unfair Treatment By Your Insurance Company

The implied covenant of good faith and fair dealing includes the duty to:

  • Thoroughly investigate the insured’s claim and to fully inquire into all possible bases that might support payment of the claim;
  • File for declaratory relief or bring other litigation against its insured only where it has a reasonable basis for doing so

If your insurance company does not treat you fairly and respond to your claim in a reasonable, professional manner, it has acted in bad faith. Our experienced attorneys may be able to recover your benefits and additional compensation through an insurance bad faith lawsuit.

My Insurance Company Said I Don’t Need A Lawyer

Insurance companies are not allowed to give you legal advice regarding your claim, and are prohibited by law from telling you not to contact a lawyer. They are not allowed to use tactics such as delaying claims, or scaring, or coercing you into accepting a settlement in order to avoid a lawsuit. Additionally, insurance companies may not compel insureds to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by the insureds, when the insureds have made claims for amounts reasonably similar to the amounts ultimately recovered.

Delaying the investigation or payment of claims by requiring an insured, claimant, or the physician of either, to submit a preliminary claim report, and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information is also illegal under California law.

If your claim has been wrongfully denied the best thing you can do is contact our law offices and let us evaluate your situation and advise you of any course of legal action you may be able to pursue.

Get Your Free Consultation With An Experienced Hayward Insurance Bad Faith Attorney Today

There are many ways in which an insurance company may have acted unfairly that you may not realize are illegal. Before you except a settlement offer, sign away your rights to sue, or even accept that an insurance company’s decision if the final word call our law offices for a free initial consultation and get an honest answer about your rights. To learn more about how our attorneys can help you, schedule a free consultation today. We represent clients in communities throughout Northern and Southern California. Call us at 877-664-5407 or contact us online to schedule an appointment.