Navigating Bad-Faith Insurance Claims for Quality Healthcare
At Turner Law Group, we understand that facing the aftermath of an accident, particularly dealing with injuries, can be an overwhelming and challenging experience. At such times, your focus should rightfully be on your health and recovery. However, the unfortunate reality is that many healthcare insurers engage in bad-faith practices, hindering your access to quality care and complicating an already difficult situation.
By allowing insurance companies to dictate patient care, injured victims are put at a high risk of harm. Holding insurers accountable for acting in bad faith is critical to improving health and restoring your right to make informed decisions. In this post, we’ll explore the impact of prior authorization and other bad-faith tactics by insurers and review 5 steps injured victims can take to ensure their recovery.
What Constitutes “Bad Faith” Insurance?
Under Illinois law, insurance companies are bound by a duty of good faith and fair dealing with the individuals they insure. This duty is implicit in all insurance contracts, requiring insurers to:
- Respond to claims within a reasonable timeframe;
- Make a diligent assessment of each claim; and
- Provide a basis for claim denials.
When an insurer deliberately misinterprets records or policy language to avoid paying a claim, fails to disclose policy limitations and exclusions to policyholders, or unnecessarily delays the processing of claims, this constitutes bad faith. Likewise, if the insurer fails to communicate pertinent information to the claimant or to conduct a comprehensive investigation of the claim, this is also considered acting in bad faith.
Victims of bad faith insurance practices in Illinois have the right to bring a lawsuit against the insurance company and recover damages. It’s crucial to secure experienced representation from a qualified attorney who can protect your rights and ensure you’re compensated fairly.
What Is Prior Authorization in Health Insurance?
Prior authorization is an insurance process that requires healthcare providers to obtain approval from the insurance company before prescribing a treatment, a medication, or a healthcare service to the patient. This process aims to ensure the service is medically necessary and reduce healthcare costs by controlling access to more expensive treatments.
However, this policy may be doing more harm than good when it comes to protecting injured victim’s safety and well-being. Thanks to bad faith insurers, prior authorization has seriously undermined the ability of physicians to deliver appropriate, high-quality care to their patients, many of whom rely on their doctors to help manage chronic pain and improve daily living after an accident.
Today, prior authorization and other bad faith strategies can result in serious risks to patients, including:
- Delayed treatment: Obtaining prior authorization can take significant time, leading to extensive delays in starting essential treatments while increasing the risk of adverse patient health outcomes.
- Increased administrative burden: The PA process can be complex for healthcare providers to navigate, demanding time and energy for paperwork and bureaucratic hurdles instead of administering quality care to patients.
- Treatment denial: Insurance companies often deny authorization for the use of certain medications or treatments, forcing doctors to seek less effective treatment options.
- Heightened stress for patients: The uncertainty and waiting inherent in the prior authorization process can increase anxiety and stress for patients in need of prompt and definitive care, causing their health to worsen.
Healthcare insurers often use prior authorization to their advantage by:
- Containing costs: Limiting access to certain expensive treatments helps keep the insurers' costs down.
- Shifting the burden: By making the process arduous, some insurers bank on doctors and patients giving up on pursuing the necessary authorization, reducing expenditure while making prior authorization a full-time job for physicians.
- Undermining physicians: Insurance companies position themselves as the final arbiters of treatment, superseding the expertise of healthcare professionals and leading to suboptimal patient care.
How Insurance Companies Cut Costs at Patients’ Expense
The unfortunate reality is that insurance companies have a reputation for acting in bad faith to cut costs for themselves at the expense of patients. Insurers employ various strategies to cut financial corners, including:
- Pre-certification: Determining how long a patient can stay in the hospital.
- Concurrent review: Determining the medical necessity of tests and procedures when a patient is hospitalized or receiving treatment.
- Non-medical switching: Forcing stable patients to change medications to cut costs and maximize profit.
- Step therapy: Limiting patients to the cheapest available options before “stepping up” to costlier treatments, allowing the patient’s condition to worsen in the meantime.
- Retrospective review: Determining coverage after the treatment has already been administered.
5 Steps to Take if Your Insurer Acted in Bad Faith
As an injured victim, it’s normal to feel angry and helpless after suffering harm due to bad faith insurance. If you suffered delayed care or related harm due to prior authorization policies, seeking sound counsel is critical to recover the compensation you rightfully deserve. Fortunately, there are steps you can take to pursue justice.
Patients can take these 5 steps to negotiate a bad-faith insurance claim:
- Document everything: Create a detailed record of all interactions with your insurance company, including dates, times, names of representatives, and the specifics of conversations or correspondence related to prior authorization.
- Obtain medical documentation: Gather all medical records that detail the required treatments and the impacts of any delays or denials on your health. This includes doctor’s notes, treatment plans, and records of any adverse health consequences.
- Secure trusted legal representation: Consult with a personal injury attorney with extensive legal knowledge is paramount. Your lawyer can evaluate your case with a practiced legal eye and guide your steps wisely to secure a favorable outcome.
- Appeal the denial: If your treatment was denied, file a formal appeal with your insurance company. This step is often a prerequisite for taking further legal action, so ensure that you comply with the specific procedures outlined in your plan.
- File a claim: Your attorney can help you file a claim to pursue justice and recover damages for medical costs, emotional distress, and other losses.
40+ Years of Experience Advocating for Wronged Patients
When any healthcare company puts profit over people, adverse health effects are guaranteed to follow. At Turner Law Group, our Illinois attorneys are here to protect your rights and represent your best interests after a wrongful injury. With a comprehensive knowledge of medical malpractice, bad faith insurance, and personal injury law, you can trust our highly skilled lawyers to advocate on your behalf and negotiate effectively to achieve the fair settlement you deserve.
If you were harmed by a bad-faith insurance claim, turn to Turner Law Group for reliable representation. Call (800) 653-0198 to schedule a free consultation.