Health Insurance Coverage, Claims & COVID-19
The COVID-19 outbreak has some Coloradans wondering about their health insurance will cover, what to do if they have a claim denial, and, for those without insurance, if they can get coverage now.
Uninsured Coloradans Can Get Coverage
If you currently do not have health insurance, the state of Colorado has opened an emergency special enrollment period. You can enroll in the state’s health insurance marketplace from now until April 3, 2020. Insurance takes effect April 1.
This special enrollment period is also open to people who are about to lose their health insurance.
You may also be eligible to enroll in a new plan if your income has been reduced due to the novel coronavirus pandemic.
Coverage by Employer & Other Private Health Plans
Your private health insurance covers COVID-19 infections much like it would other illnesses. You still face out-of-pocket costs, such as co-payments, coinsurance, and deductibles before your coverage takes over. That can mean thousands of dollars depending on your plan.
Colorado Governor Jared Polis has ordered the Colorado Division of Insurance (DOI) to issue guidelines for insurance plans regulated by the DOI. So how will you know if your insurance is regulated by the state’s DOI? Just look at your insurance card. If you see CO-DOI stamped on the bottom corner of your card, the DOI regulates your plan.
The DOI issued the following insurance coverage requirements:
- Free COVID-19-related telehealth, or tele-doc, visits
- A free, one-time early refill for all necessary prescriptions
- Free COVID-19 testing
- Waive cost-sharing for in-network provider office visits, in-network urgent care visits, or emergency room visits when a covered person seeks a COVID-19 test
Read the full descriptions of the DOI insurance coverage requirements here.
The federal Families First Coronavirus Response Act requires that FDA-approved coronavirus tests are free.
What to Do About a Claim Denial
Health insurance companies are obligated to cover what’s in your policy. If your experience a COVID-19 claim denial, you have the right to appeal.
The Appeals Process
The appeals process for a claim denial is a lengthy one. It begins with an internal appeal. The insurance company is asked to conduct a full and fair review of its decision to deny your claim.
You’ll either have to write a letter to your insurance company or fill out a form it provides that contains evidence you have collected to show why you must have the medical treatment or service you sought.
If the insurance company decides to let the claim denial stand, you can request a second internal review. The second internal review requires a healthcare professional who was not involved in the original review to examine the claim.
You are allowed to be present for the second review and bring an attorney with you.
If you claim is denied after the second internal review, then you can request an external review by a third part to review the issue.
In Colorado, the independent external review entity is appointed by the Colorado Division of Insurance.
Following the decision of the independent reviewer, either party (you or your insurance company) can challenge the decision in court.
Bad Faith Claims
Your insurer is acting in bad faith if it unreasonably or wrongfully delays or denies your claim.
When you file a bad faith claim against your insurance company, state law requires you to prove the following:
- The insurer’s actions in denying or delaying payment were unreasonable under the circumstances.
- The insurer either had knowledge of or reckless disregard for the fact that its actions were unreasonable.
If your insurance company delays your COVID-19 claim or denies it, you may have a case.
Insurance companies benefit when you don’t stand up for yourself. You have the right to appeal denials and fight back against bad faith practices.
You could be entitled to compensation beyond your health benefits if your health insurer has acted in bad faith.
Call 303-688-0944 to set up a convenient time to talk with an attorney over the phone.
Can I Get Workers’ Compensation for COVID-19?
When someone sustains a work-related injury, workers’ compensation insurance is supposed to pick up the tab for medical expenses and even pay some of your lost wages.
So, does this mean you’ll be covered if you get sick with the respiratory illness while working? Maybe.
In Colorado, there are multiple workers’ compensation insurance carriers, unlike some states which have only one fund that is overseen by the state. That means, coverage for a possible work-related COVID-19 infection, including a test for it, depends on the carrier’s policy.
Most Colorado carriers report coverage can only be determined after a full investigation of the claim. Carriers determine what elements are required for a complete investigation.
What do I do if I Got COVID-19 at Work?
The first priority if your health. So seek the medical attention that health officials are currently advising related to your symptoms.
Next, you’ll have to report it to your employer. Typically, employees have four working days to report an accident in writing. However, for injuries that occur over time, you should report it to our employer as soon as you realize you have a medical condition caused by your job.
Employers have 10 days to file a claim to the insurance carrier. This is called the Employer’s First Report of Injury.
What to Do if Your Workers’ Comp Claim is Denied.
For many people, a COVID-19 infection is mild. Others, though, will experience serious problems that land them in the hospital for days, even weeks. This means major medical bills and lost income.
If your workers’ compensation claim is denied, you should follow these steps:
- Contact the insurer to find out why the claim was denied. This information will help determine your next step. The dispute may be easily resolved by clearing up a clerical error or submitting more information.
- If you believe your claim was wrongly denied, and there doesn’t appear to be an easy resolution, you may want to appeal the decision.
- File an Application for Hearing within 45 days of the date of mail on the Notice of Contest. The Notice of Contest should provide deadline dates and contact information for mediation and hearings. You may also directly contact the Colorado Division of Workers’ Compensation.
Appealing a workers’ compensation claim can be lengthy and complex. You may want to hire a worker’s compensation attorney who can guide you through the process and act as your advocate.
For more information about workers’ compensation appeals and tips on how to file a successful claim, check out this free legal guide.
Robinson & Henry, P.C. | Insurance Attorneys
If you have a COVID-19 insurance-related issue, like a claim denial, our insurance attorneys can assess your situation to see if you have a claim, and if you do, they can help you navigate the process.
We’re talking to potential clients and clients over the phone due to COVID-19. So you don’t have to worry about getting sick or spreading the illness.
Schedule a time to talk with an attorney for free over the phone at 303-688-0944. You can also set up a time online.