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Health Insurance Benefits

NATIONALLY RECOGNIZED. CHICAGO STRONG. HEALTH INSURANCE LAWYERS

Bartolic Law has helped clients in every stage of health insurance challenges and disputes, including pre-claim advice to avoid denials, appealing denials, and lawsuits over health benefits under ERISA § 502(a). Health insurance denials and delays in approval have been on the rise. We understand the frustration. Your premiums, coinsurance, and copays increase every year, and the policies cover fewer and fewer things. Yet when you need the insurance, it is not always there. Clients find themselves in all kinds of challenges. Unfortunately, too few lawyers understand the health insurance system structure to understand how to approach the disputes. Bartolic Law has helped clients with all kinds of health insurance issues, including:

  • Medical Necessity of Spinal Surgeries
  • Denials of Residential Treatment
  • Employers’ Failure to Enroll a Participant in Plan
  • Denials of Medication Treatment as Experimental
  • Exclusions for Work-Related Injuries
  • Denials of Fertility Treatment
  • Refusal to Pay After Pre-Authorizing Surgery
  • Misclassification Procedures as Cosmetic
  • Emergency Exceptions to Out-of-Network Providers
  • Misapplication of Exclusions Due to Third-Party Caused Accidents
  • Denials of Gender Reassignment Services
  • And More

HEALTH INSURANCE DENIALS

Nothing is more frustrating than needing health treatment, and not getting it. We understand. We live in the country with the largest economy in the world, and your health is managed (or mismanaged) by for-profit entities. The entities search for ways to make more money, which does not generally include providing you with better benefits, or covering more of what you need. As a judge in one of our recent cases stated in an opinion, “this case is a prime example of why so many people are so enraged with the health insurance system.”

Health insurers often assert treatments are not medically necessary. The plans define medical necessity, but the insurers often write their own internal guidelines on medical necessity that does not match the plan’s definition, causing countless wrongful denials.

Insurers often refuse to authorize a medically necessary procedure, without which you may experience severe consequences to your health. If you can get the doctor to perform the procedure without pre-authorization, it is easier to fight the denial of payment than get the pre-authorization. But then you must be diligent about challenging the denial.

SUCCESSES

SUCCESS GETTING MULTIPLE SCLEROSIS TREATMENT PAID

Bartolic Law helped a client suffering from Multiple Sclerosis get continued treatment with an expensive medication after the insurer cut off payment for the treatment. The medication costs approximately $10,000 per month, and the insurer paid for it for 6 years. Then it abruptly stopped covering the medication, asserting it was not medically necessary, as treatment with that drug ordinarily does not last longer than 2 years. We were able to show that the insurer’s guidelines were not in line with medical necessity and that the past 6 years of treatment had helped the client. We were able to resolve the matter for the client so he could continue to manage that devastating disease.

SUCCESS GETTING SPINAL CORD STIMULATOR SURGERY PAID

Health benefit plans often cover medical expenses incurred when you suffer an injury caused by another person, but then get reimbursed from the settlement. The plans often state they will exclude any further treatment for the injury. Bartolic Law helped a client get a costly surgery to remove a spinal cord stimulator removed when the plan denied the claim. The plan contended that because the spinal cord stimulator was inserted due to the third-party caused injury, any further treatment related to the spinal cord stimulator was excluded as “caused by the same injury.” We demonstrated that the reason the client needed the stimulator removed was that she fell down stairs in her own home years after the car accident, causing an infection at the site of the stimulator. Her doctor advised if she did not get the device removed immediately, the infection could migrate to her spine and cause permanent damage. Using detailed accounts of the in-home accident and progression of the infection, we won the case in court and obtained full relief for our client.

SUCCESS OBTAINING PAYMENT OF COSTS OF CHILDBIRTH

Bartolic Law helped a client who was pregnant when her employer changed health insurers, but it never enrolled her with the new insurer despite collecting health insurance premiums from her. The employer appeared to just forget to include her, and when she delivered her baby, the previous insurer denied the claim because it was no longer the insurer, and the new insurer denied the claim because the employer did not enroll her. We were successful in getting the employer to cover the medical costs, subject only to contribution from our client equivalent to what she would have paid had she been enrolled in the insurance.

SUCCESS IN STOPPING A BROKER FROM EVADING LIABILITY FOR FAILURE TO BIND AN EMPLOYER’S HEALTH INSURANCE

Bartolic Law represented a client that had herself and her terminally ill husband enrolled in the employer’s health insurance plan. The employer fully insured its health benefits, until a broker approached the employer and proposed to save the employer money by structuring the health plan as self-insured with stop loss insurance (which operates like very high deductible health insurance for the employer). After adopting the new plan structure, and our client’s husband’s astronomical bills were not being paid, the client learned the broker and the third-party administrator never bound the stop-loss insurance, yet disclaimed any responsibility for doing so. In a brilliant opinion, Judge Johnston wrote: “[I]f the allegations made by the plaintiffs and third-party plaintiff are true, then this case is a prime example of why so many people are so enraged with the health insurance system.”

SUCCESS SHOWING SURGERY TO FEMALE’S GENITALIA WAS NOT COSMETIC

Bartolic Law helped who required surgical modification to her labia to permit her to conceive a child through natural intercourse. The insurer denied the claim, contending the surgery was cosmetic. Thanks to our client’s trust in us, and our professionalism, we were able to show the insurer why the deformity required surgery for a medically necessary reason and was not a cosmetic procedure.

DO NOT IGNORE A HEALTH PLAN’S DENIAL

Before you can file a lawsuit under ERISA § 502(a) against an employer-sponsored health plan, you must exhaust all the required appeals. You only have 180 days to complete each of those appeals, but that is not as much time as it seems. The Court will usually only review the record created during those appeals, so getting the right help when the plan denies your claim can make a tremendous difference. Also, do not ignore the appeal rights. Often, insureds do not call a lawyer until the hospital puts the unpaid bills into collection. If you do not act on the plan’s denial within those 180 days, you will forfeit your right to file a lawsuit. ERISA provides the ability to shift attorney’s fees to the insurer or plan if you win in court.

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