Health Insurance/HMO Coverage

It can be confusing and stressful for consumers to deal with the multitude of issues surrounding health insurance: What is covered? What is excluded? When do I need pre-authorization? What am I required to pay? Co-pay? Can I see this specialist? How do I appeal or challenge an adverse decision? You may have a Preferred Provider Organization (PPO) Plan that pays medical bills after they are incurred or you may be covered by one of the various HMOs operating in California which generally require "pre-authorization" of certain treatments and procedures.

Having been defense counsel for various health insurance carriers, medical groups and independent physician associations, also known as independent practice associations (“IPA”), Los Angeles insurance lawyer, Eduardo A. Brito, has developed a wealth of knowledge as to how health insurance works, how it should work, and what a consumer should do when it doesn’t work. Whether you have a PPO or HMO, your health insurance company must treat you fairly and comply with its obligations under your health plan. This includes moving quickly and acting fairly to resolve claims.

When health insurance companies unjustly deny claims for benefits, the costs can be damaging to your physical health as well as your financial health. The Law Office of Eduardo A. Brito want to make sure that your physical and financial health are safeguarded and that you are not taken advantage of by insurance companies that put their bottom-line ahead of your well-being.

Your health insurance company may try to justify its denial of your claim for benefits by arguing various positions, including the following:

  • Your doctor's office entered the wrong code or duplicate billing code
  • The type of service you obtained is not covered under your plan
  • Your policy limit has been exceeded
  • The procedure you want/need is “medically unnecessary”
  • The procedure you want/need is “experimental” and not covered
  • The provider you want/need is out of network
  • Te treatment you seek is related to a preexisting condition
  • Your health insurance application contained false, inaccurate, or incomplete information

Whether the denial of your claim for benefits is reasonable or justified depends upon the terms of your policy and all the facts surrounding your claim. For example, some plans require an approved primary care physician (“PCP”) to act as a “gatekeeper” before you see any specialists, while other plans may only require advance notice or no notice at all. With his years of experience interpreting health insurance policies, Los Angeles insurance lawyer, Eduardo A. Brito, will help you fight against an unreasonable denial of your claim and will protect your rights to obtain the medical care and treatment you are entitled to receive.