*Loan,banking and credit>>>health insurance

Do I need to hire a lawyer to fight against health insurance company for denied claims?

I am having problem with my health insurance company who denied coverage. There is $50,000 outstanding balance, which supposed to be covered, but were denied, because of I am also listed under my husband's health insurance.

The claims were re-routed to both insurances.... and I haven't contacted the State agency (Dept of Insurance?) yet.

On the State agency's web site, it saying "If you have an attorney representing you in this matter or if there is a lawsuit currently ongoing or pending, our ability to mediate this matter is limited, but we will investigate your inquiry for any regulatory issues. However, if a lawsuit is pending, we may defer the regulatory investigation until the finality of the litigation. We ask that you still complete this form so we have a record of your issue."

The original service was rendered 6 month ago... and I am losing time.

Shoud I file a complaints to State agency first, and wait for what they are come up with? OR hire an attorney now?

Well, what's the TIME FRAME? Will they honor claims filed within 180 days, or 365?

I'd be VERY inclined to do the insurance department first - an attorney is going to cost you money up front, and they're not likely to be able to DO anything for you.

I'd ALSO be inclined to gather up all the paperwork, INCLUDING COPIES OF BOTH POLICIES, and truck it down to have a meeting with your homeowners insurance agent, and get THEIR opinion - free of charge.

Your policy would be primary. Depending on WHY your policy declined to cover, then your husband's should be secondary, covering you. So, the declination from the primary carrier should trigger coverage from the secondary, unless we're talking about an uncovered procedure here (like cosmetic surgery).

You need to have both claim EOB's, and both declination letters, to send to the insurance department. Now, they're usually pretty fast, you'll likely have a response within two weeks. And normally, the "180 days" retriggers from the date the claim was denied, so that should buy you a little more time. Source(s): agent, 21+ years

If you have two coverages the following is the procedure that needs to be followed in order to get the secondary coverage to pay.

1) Definition of Primary carrier: Primary coverage is the coverage that the member gets through their employer as an EMPLOYEE.

2) Definition of secondary carrier: Secondary coverage would be defined as the coverage the member has through their spouses plan if the member also has coverage through their OWN employer.

ALL the bills need to be sent to the primary carrier first - it is important that the claims be processed and you have copies of all your Explaination of Benefits (EOBs) from your primary carrier. It is also important that all the claims be paid correctly and there is nothing outstanding on the EOBs that needs resolution.

THEN and only THEN all the EOBs from the Primary carrier can be sent to the SECONDARY carrier. The secondary will not pay a bill unless the primary has completed their part.

The problem arises when bills are sent to the secondary carrier before all COVERED claims have been paid by the PRIMARY - the secondary will not do anything until this is accomplished.

For you - to make sure this is happening you need to match each EOB with the correct bill from the various providers - this way you can see that all the providers have applied the correct payments from the carriers. When you are matching EOBs - match them by Date of Service (DOS).

Before you go to a lawyer its best to see exactly where you stand, most of these issues arise because of billing errors. This is because the providers are not very good at billing the two benefits - coordination of benefits is a hassel.

I hope this helps - feel free to contact me if you want to discuss.
http://www.KnoxAssociates.net
Your insurance should pay first, because it's your primary coverage. Whatever isn't covered by your plan will most likely be picked up by your husband's medical plan.

You need to find out EXACTLY WHY your claim was denied - what was the insurance company's reason?

Once you know the reason, you may file an appeal with the insurance company, and you may also file a complaint with the state insurance commissioner.

Just FYI - the claim has already been submitted to your insurance company, so you're not working against a filing deadline. A filing deadline means a claim has to be submitted to your insurance company within a certain amount of time - you've already done that, so don't stress about timelines.

Personally, I don't see a reason to hire an attorney at this point. You just need clear understanding of WHY the claim was denied, and make sure the claim was filed FIRST to your insurance company and SECOND to your husband's.