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The first employee benefit that most employers offer is medical insurance. The state of the U.S. medical system requires comprehensive medical insurance. Because of this great need, medical coverage might not be just the first incentive beyond a wage that an employer will offer – it can sometimes be the only one.

Offloading medical costs is a major concern for employees. That protection can equal or even exceed the value of the weekly wage.

However, health insurance protection is not always what it seems. Insurance companies are known for creating obstacles and denying medical claims. Among others, providers such as Blue Cross Blue Shield, Anthem and United Healthcare often use terms such as “not medically necessary” or “experimental treatments” in denials of health benefits that should be covered. This is in addition to the flat-out insurance denials due to a medical treatment, visit or procedure not being covered under the policy.

Many times, the status of a claim as medically necessary or experimental (or simply not covered) is decided by an employee of the insurance company. The only person who should be able to determine whether your care is medically necessary is your treating physician. While there are instances when a particular policy expressly does not cover a treatment, many times a denial of health benefits stems more from a lack of information and an insurance company’s hasty, incomplete decision-making.

If your employer-provided health benefits have faced denial of coverage for a medical treatment, visit or procedure, you have rights to dispute a wrongful denial of benefits and even file a lawsuit.

Like all employee benefits (e.g. long-term disability, short-term disability, 401k, life insurance), your health benefits are governed under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA requires the claim administrator to provide an internal review of any employee benefits denials, including coverage for medical treatment.

The best time to produce all necessary information regarding the health benefits denial and demonstrate why the care is medically necessary or why the treatment is covered under the policy is during the internal insurance appeal or review process.

This process is best handled by an ERISA lawyer who knows what ERISA requires, what information is needed to prove medical necessity and how to work with physicians to get the right language in front of the insurer. Without such specialized knowledge, an employee contending with a benefit denial can easily have their insurance appeal review neglected. Following the insurance appeal, the carrier also can rely on the opinions of in-house physicians to support the health benefit denial.

In addition, if the insurance appeal is denied and a lawsuit is necessary, the federal court is limited to reviewing only what has been submitted to the insurance company during the initial benefit determination or during the internal appeal. ERISA makes it necessary that a lawyer handle the appeal.

The ERISA lawyers at Gallagher Davis, LLP specialize in handling appeals of the wrongful denial of employee health benefits. We know how to properly set up the insurance appeal so your medical care is covered under your employer-provided medical insurance. That skill also allows us to prepare the claim file in the optimal way to succeed if the filing of a lawsuit is necessary.

Lawyers for ERISA & Employee Benefit Litigation: Contact Us Today

You do not have to allow an insurance company to dictate what is medically necessary or covered under your policy.

With experience in all state and federal trial and appellate courts in the St. Louis metropolitan area, as well as federal courts throughout Missouri and the Midwest, our ERISA lawyers provide you with vigorous advocacy and representation in justly receiving employee benefits to which you are entitled.

If you have experienced a wrongful denial of benefits for a medical treatment, visit or procedure, call us at (314) 725-1780 to discuss whether you have a cause of action or if we can help you file an internal appeal of the insurance denial.