When you have health insurance through your employer, you present your card to the doctor upfront and expect your bill to be covered. Unfortunately, oftentimes people are first made aware that a health insurance claim has been denied when they receive an unexpected bill from their doctor’s office. Maybe you even received a pre-approval letter, but then you find out your claim was denied. It’s overwhelming and nerve racking to find out your claim was denied, and you have an unexpected expense you can’t afford.

Earlier this year, The Atlantic stated that ”according to a survey published … in the American Journal of Public Heath, nearly 60 percent of people who have filed for bankruptcy said a medical expense ‘very much’ or ‘somewhat’ contributed to their bankruptcy.” The Atlantic also stated that advocates mentioned that emergency-room visits and planned surgical procedures tend to be the most common reasons for large medical bills that patients aren’t able to pay for. These expensive procedures are the reason why many people invest in health insurance in the first place, unfortunately sometimes the insurance doesn’t work the way it is supposed to.
The first step for most people facing an unexpected medical bill is to call their health insurance company to find out why the claim was denied. The insurance company will probably invite you to appeal the denial, but it is unlikely that they will explain just how important the appeals process is. If you get your insurance through an employer, it is probably subject to special rules through ERISA. ERISA stands for the Employee Retirement Income Security Act and is a federal law that regulates most employee benefits received through an employer. During the appeals process, the administrative record is formed. The administrative record is the only evidence that a judge will consider if the case ends up going to court. There are many reasons that a health insurance claim may be denied, and you want to be fully prepared to appeal the claim to your health insurer and build the strongest case possible in the event that you must take the case to court.
Attorneys Bryan and the ERISA team helped a client, Chris, through a denied health insurance claim during a situation that involved an emergency procedure following complications from a planned surgery. After his emergency surgery, Chris started receiving multiple medical bills, some over forty and fifty thousand dollars. Chris didn’t have the money to pay the bills out of pocket and was afraid about what the denial would do to his credit and his ability to provide for his family.

Through their experience with ERISA and health insurance, Bryan and the ERISA team knew Chris should have gotten an independent review of his claim during the appeals process. Chris’s insurance plan did not include this option, but Bryan and the ERISA team worked to successfully get Chris’s claim reviewed by an independent reviewer. The reviewer determined Chris’s claim was covered. They were ultimately able to get the insurer to agree to pay Chris’s claim, erasing six-figures of medical debt, cover all attorney’s fees, and they amended the plan so that Chris’s coworkers would not have to go through the same hardship he did.
At Marcellino & Tyson, PLLC, our team of extremely knowledgeable and experienced attorneys understand the processes involved with denied health insurance claims. Bryan and the ERISA team are dedicated to helping individuals recover their benefits and receive the coverage that they deserve. To learn more about Chris’s story, check out the video below.

The purpose of Marcellino & Tyson’s blog and information postings is to provide news, general information and a general understanding of the law. All content is for informational purposes only and is not legal advice. In addition, reading our informational news does not establish an attorney-client relationship. If you are seeking legal advice, we encourage you to contact an attorney to evaluate your needs.