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When a insurance company does not pay or deny medical claim in a timely manner?

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The Florida statute 627.6131 (5) (e) ,,A claim must be paid or denied within 120 days after receipt of the claim. Failure to pay or deny a claim within 140 days after receipt of the claim creates an uncontestable obligation to pay the claim.,, Later it states ,,Payment of a claim is considered made on the date the payment was mailed or electronically transferred. An overdue payment of a claim bears simple interest of 12 percent per year. Interest on an overdue payment for a claim or for any portion of a claim begins to accrue when the claim should have been paid, denied, or contested. The interest is payable with the payment of the claim.,, My insurance company did not deny within 140 days, I have paid all 3 claims out of pocket, what can I do to get the money back?

I have submitted a letter of appeal for these claims, but I was not aware of The Florida statute 627.6131 (5) (e) when I did. The insurance company must have know when they denied my claims that they had long past the time they had to deny according to the statute. Is that lawful? One more thing, can an insurance company change there reason for the denied claim (as on the EOB) when faced with having to pay?

Attorney Answers 3

Posted

Seek legal help with your paperwork. Not possible to answer your questions without seeing the paperwork.

The answers given are limited to the facts as given and presumed by the answer itself. Without seeing actual written documentation or having a conference to more fully explore the issues, this short answer has only limited application. Make sure to seek legal counsel and provide all documentation to get assistance in making informed legal choices.

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6 comments

Asker

Posted

I understand, but I thought that statute 627.6131 was literally by the book, pay or deny within 140 days...or the insurance company has to pay....

Barry A. Stein

Barry A. Stein

Posted

Nothing in the law is as easy or simple as that. Sure it may apply but all your paperwork must support its application as well. ERISA the Federal statute may preempt the area also. Too many details are missing to answer your inquiries.

Asker

Posted

Oh I see, but I have a Travel medical insurance as I am a foreigner and paid for it myself. I must admit that I have totally lost faith in the insurance system and I think I would have been better off not having an insurance for my son while he was in the USA. I feel like the whole thing is a scam

Barry A. Stein

Barry A. Stein

Posted

Have an attorney review the policy and the paperwork. Their failure to allege an appropriate reason wont bootstrap you into a win. I am also curious whether the policy is "health" insurance as that term is used in the Florida Statute. It may not be and therefore not subject to the provision you quoted.

Asker

Posted

Thanks Barry, you are right....after staying on the internet the whole night I have found out that this is a International major medical and is regulated by the State of Indiana in as Third Party Administrator...I give up....I will now turn my attention to the insurance broker that sold me plan, as he did not include in the policy what I asked for (I have that on e-mail) Thank you again for all your help....

Barry A. Stein

Barry A. Stein

Posted

best of luck.

Posted

No way to answer without seeing the docs, so have a local lawyer review them

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Posted

In order to answer your question properly, an attorney needs to go over the facts and the documentation to determine what appropriate steps are need to proceed with a potential case against the insurance company. Good luck.

Miguel A. Amador is licensed to practice law in Florida and the District of Columbia only. The information provided is for general informational purposes only and is not intended to be legal advice. No attorney-client relationship is formed nor should any such relationship be implied. The information provided is of a general nature is not intended to substitute for the advice of an attorney

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