Most of our clients first come to us shortly after they receive a telephone call or letter informing them that their claim has been denied or terminated.  You may be in the hospital and your treating physician recommends a particular medical procedure or a longer stay, but your insurer refuses to approve coverage.  Or you may have been on disability for several years, but suddenly your insurer tells you that you are well enough to return to work.  Or perhaps your insurer has denied your claim for disability in the first place.  We can assist you in preparing the appeal to reverse such benefit denials and terminations.

Since most people receive their insurance coverage through their employer, many of these claim denials will be governed by a federal law called the Employee Retirement Income Security Act (ERISA), which governs coverage and benefits under most employer-sponsored pension and benefit plans.  ERISA provides a wide variety of procedural requirements and protections, including a mandatory internal appeal procedure.  We can assist you in enforcing your rights - which may include your entitlement to plan booklets and insurance contracts, as well as reports, emails, telephone logs and other documentation reflecting your insurance company's handling and determination of your claim.  We can review your plan booklet and claim file and advise you on how best to prepare an effective appeal.

We can also advise you with regard to other rights you may have under New York law and other federal laws.  New York, for example, provides an "external review" procedure for certain kinds of health care claim denials -typically, those where the denial is based on an alleged lack of medical necessity or on the purported experimental/investigational nature of the treatment.  External reviews, which are subject to strict deadlines, may be available in addition to, or in place of, ERISA internal appeal procedures. Because external reviews are conducted through the New York State Insurance Department, you may feel that such review is more likley to provide a fair and independent determination of your claim. 

We try to provide flexible levels of service to accommodate the different functional and financial needs of our clients.  If a client feels able to write an appeal, we can participate in an advisory capacity -- providing initial suggestions and then commenting on draft versions of the appeal.  If a client is able and willing to do leg-work, such as obtaining medical records, this can reduce attorney time dramatically.  Similarly, client questions presented by letter, fax and e-mail, can sometimes be more efficient and cost-effective than doing so by telephone.  Finally, in certain appropriate cases, a contingency fee arrangement may be mutually satisfactory (rather than a straight hourly billing arrangement).  Such an arrangement may not reduce the amount of fees ultimately paid, but may postpone the fees until an award or settlement is achieved.