There are several laws that could potentially govern the administration and operation
of your health insurance. If you are receiving health insurance from a "group benefit
plan" sponsored and administered by your employer, then your coverage is more than
likely governed by the Employee Retirement Income Security Act ("ERISA"). If you
have health insurance through an individual policy, then it is more than likely
governed by state law (e.g. the Deceptive Trading Practices Act). The administration
of your health insurance may also be governed by the Health Insurance Portability
and Accountability Act ("HIPAA"). HIPAA sets forth the rules that govern for an
individual's protected health information and the application of pre-existing conditions.
What are some examples of Health (Medical) Insurance Disputes?
Experimental and Investigatory Treatment. If a group benefit plan excludes
experimental and investigatory treatments, then the issue arises of what constitutes
an "experimental or investigatory" procedure. Federal case law has set forth
standards and factors to consider on what constitutes an "experimental and
investigatory" procedure. If you, or one of your family members has been denied
medical treatment because of this reason, you should contact us to determine
whether (and how) you should appeal your denial.
Pre-existing Conditions. Some health plans have a "preexisting" clause which
restricts the coverage of medical conditions that existed prior to being covered by the
current group benefit plan. The application of this type of clause can become even
more complicated when the employer has switched insurance carriers or the
employee was forced to take a leave of absence and had to reapply for his original
position. Preexisting conditions are governed, in part, by the Health Insurance
Portability and Accountability Act ("HIPPA"). In several situations, a court has
determined that the plan administrator (or the insurance carrier) misapplied the plan's
preexisting condition clause or the application of the plan's provision was illegal.
Subrogation. Health insurance plans (also referred to as "group benefit plans")
generally have a subrogation clause. A subrogation clause generally requires the
repayment of health benefits paid by the plan if an individual's illness or injury was
caused by a third party and the participant recovers money related to those benefits.
The application of this clause can become complex when attorneys fees, legal costs,
and other amounts of recovery are involved in the settlement.
If you have a health (medical) insurance dispute, please Contact Us, so we can review
your case.
contents of this website should be forwarded to mikeforni@erisa-litigation.com. All Copyrights
Reserved 2004. "WARNING" - This website provides only general information for reference
purposes only, and should not be relied on any respect. Visitors should consult with legal
counsel in order to assure a thorough and proper application of the complex rules that are
highlighted here are properly applied.
