What Should You Do if Insurance Denies an Oregon Medical Claim?

When you pay for insurance, it gives you peace of mind that you will not be dealing with severe debt if you have a medical emergency. Unfortunately, you may be shocked to find that your insurance claim has been denied. If you do not appeal, that can leave you paying out of pocket for extensive medical debt.

However, an insurance denial is not necessarily the end of the story. While this denial indicates the insurance company’s refusal to pay, you have options as an insurance policyholder. Know your rights before you accept a claim denial from your Oregon medical insurance company.

You Have a Right to Appeal Your Medical Insurance Claim

When your insurance company denies your medical insurance claim, you have a right as a policyholder to appeal that decision. That can start with appeals within the insurance company, but if they act in bad faith or refuse to take action, you have other opportunities. Below are the two main ways you can appeal your insurance claim denial.

Internal Appeal

Your first option is to request an internal appeal from your insurance company. You can pursue a complete and fair review of the health insurance company’s decision, which can lead to that decision being overturned. However, even if the insurance company supports this decision, you are not necessarily out of options.

External Review

In some cases, the insurance company may continue to refuse, and they may even be acting in bad faith. In these situations, you may want to turn to an independent third party to review and potentially appeal your claim. You may even have grounds to file a complaint with the Division of Financial Regulation, which governs these cases under Oregon law and can force the insurance company to pay for your claim.

In certain situations, this regulatory system may fine the company if it refuses to comply with its policies. In extreme cases, it may even revoke the company’s license. Keep in mind that these investigations may take months to complete, but a full investigation can help you and other patients protect your rights.

Your Insurance Appeals Process

As you navigate your insurance claim, you may find yourself in the middle of the appeals process. However, you may be unsure what comes next. Fortunately, the Division of Financial Regulation can help, starting with a call or a visit to their department.

Filing a Complaint

If you believe the insurance company is not complying with its policies, you can file a complaint with the Division of Financial Regulation. This group offers advocacy for patients like you who have medical expenses that are not being covered. Once your complaint is filed, the insurance company will be notified.

Reviews from Insurer and Advocate

Following the filing of your complaint, an advocate on your side will complete an investigation. This advocate will review the policy and the company’s actions regarding your case. This process can take up to 60 days to complete.

Action from the Division of Financial Regulation

Once the division of financial regulation has reviewed the case, it will determine whether you have been unfairly denied. If it determines that the denial was unfair, it may force the company to comply and pay for your case. If the insurance company continues to refuse, it may face financial penalties.

You Have Options If You Are Denied Coverage

Unfortunately, many face unfair denials, delays, and interruptions in their coverage from Oregon insurance companies. Insurance companies are for-profit businesses, but you have rights as a policyholder even if the company prioritizes its profits. If you struggle to recover after an acclaimed denial, you can always contact Paulson Coletti Trial Attorneys PC for help.

Your medical malpractice attorney in Portland can offer guidance if mediation and external review are not enough. If you believe your claim require litigation, you can always reach out for a free consultation with our team to learn more about your opportunities. When you are ready to begin, call or complete our online contact form.