Medical/HMO Insurance – Common Issues
Medical insurance is in flux and it’s hard to figure out what is going on and where the pieces will all land. Nevertheless, some general principles can be identified which apply to both medical insurance and HMO coverage.
The most common problems involving Medical/HMO insurance involve the following:
- Whether the care rendered is covered under the policy or agreement.
- Disagreement over whether a physician’s charges were “customary and reasonable.”
- Whether treatment received or planned, is excluded because it is considered “experimental.”
- Whether care received was medically necessary.
- Whether medical services performed outside a specified service area were permitted or approved under the contract.
- Whether the coverage in question had been validly altered, modified or eliminated prior to the date of the treatment.
- Whether a company’s interpretation if its contractual obligations are inconsistent with brochures, advertisements or other representations made by company representatives at the time of sale.
- Whether applicable provisions of a plan or policy are vague and ambiguous, requiring coverage for claims that would otherwise be excluded.
- Whether the company has the right to rescind (cancel) the coverage based on its assertion that there were material misrepresentations made by the claimant in the original application.