A health insurance denial can arrive at the worst possible time, after a hospital stay, a specialist referral, or a course of treatment a patient’s doctor already recommended. When Lancaster-area residents are told their insurer won’t pay for care they believed was covered, the financial and medical consequences can be significant. Our bad faith insurance attorneys at HGSK Law Firm help policyholders push back against health insurance companies that deny claims without a reasonable basis.
Health Insurance Denials Affecting Lancaster Residents
Many Lancaster County residents receive care through Penn Medicine Lancaster General Health facilities and other local providers, only to have their insurer refuse to pay for a portion of that treatment. Denials can involve emergency room visits, imaging, surgeries, mental health and substance use treatment, or ongoing care for chronic conditions. Whether the plan is purchased individually, through Pennie, or provided through an employer, patients are entitled to have their claims reviewed fairly and in good faith.
Common Reasons Health Insurance Claims Are Denied
Insurers frequently point to reasons such as:
- The treatment is labeled “not medically necessary”
- Care characterized as “experimental” or “investigational”
- Missing prior authorization
- Coding errors or incomplete paperwork from a provider
- Claims that a condition existed before coverage began
Some denials are legitimate coverage disputes. Others reflect an insurer cutting corners on its duty to investigate a claim fully before refusing to pay.
Your Right to Appeal a Denial in Pennsylvania
Pennsylvania law gives policyholders the right to an internal appeal with their insurer, followed by an independent external review if the internal appeal is denied. As of 2024, the Pennsylvania Insurance Department administers this external review process for many commercial and marketplace health plans, allowing a neutral third party, not the insurance company, to have the final say on whether a denied service should have been covered.
Plans provided by self-funded employers are typically governed instead by the federal ERISA appeals process, which follows a different timeline and set of rules. Our attorneys can help identify which process applies to a particular denial and what deadlines apply.
When a Denial May Amount to Bad Faith
If an insurer denies a claim without a reasonable basis and knew or recklessly disregarded that lack of a reasonable basis, Pennsylvania’s bad faith statute, 42 Pa.C.S.A. § 8371, may allow a policyholder to recover more than just the unpaid claim. This can include:
- Interest on the amount owed
- Punitive damages
- Attorney’s fees
Insurance companies might also be required to pay additional consequential damages tied to the denial, such as out-of-pocket medical costs or collection activity that resulted from the unpaid claim.
What to Do After a Health Insurance Denial
Keep a copy of the denial letter, any explanation of benefits, and records of communication with the insurer. Ask for the specific policy provision the insurer relied on and request the internal appeal in writing. A qualified attorney can assist with the internal appeal process; if that’s unsuccessful, formal legal action may be the next step.
Speak with a Lancaster Health Insurance Denial Attorney
If your health insurance claim was denied and you believe the decision was unreasonable, our team can review the denial, the policy language, and your appeal options. You don’t have to fight battles with your insurance company alone; schedule your free consultation with HGSK Law Firm by calling 267-551-8782.