Health Insurance Law

How Long Do Health Insurance Companies Have to Approve a Claim in San Francisco?

Health insurance claims can be a daunting, frustrating experience, especially when you're waiting for your insurance company to approve or pay for a necessary procedure. Insurance companies in San Francisco and throughout California must adhere to specific criteria regarding timelines for processing and approving claims. Understanding these timelines and your rights as a policyholder is crucial to getting the benefits you're entitled to. DL Law Group helps hold insurance companies accountable and assists policyholders with the intricacies of filing and receiving reimbursements for insurance claims. Below are the basic timelines and general recommendations for health insurance claims in San Francisco. 

California Regulations on Health Insurance Claim Processing 

In California, two important Departments oversee health insurance companies depending on the type of insurance plan offered. The Department of Insurance and the Department of Managed Health Care are responsible for ensuring that health insurance companies comply with these rules and regulations about the timely processing of claims. The major regulations include: 

• Standard Claim Processing Timeframes: Under California law, health insurers must acknowledge receipt of a claim within 15 working days for electronic claims or 30 calendar days for paper claims. Once acknowledged, insurers are required to decide on the claim (approve, deny, or request additional information) within 45 calendar days for non-urgent claims, unless the policyholder agrees to an extension. 
• Urgent Care Claims: For claims involving urgent medical care where a delay could seriously jeopardize the policyholder’s health, insurers must decide within 72 hours of receiving the claim. This applies to situations requiring immediate medical attention, such as emergency treatments or pre-authorizations for critical procedures. 
• Pre-Authorization Requests: If a medical procedure or treatment requires prior authorization, insurers must respond within five business days for non-urgent requests or 72 hours for urgent requests, as outlined in California’s Health and Safety Code. 
• Appeals Process: When a claim is denied, policyholders have the right to appeal the decision. Insurers are required to resolve standard appeals within 30 calendar days, and expedited appeals (for urgent situations) must be resolved within 72 hours. If the insurer fails to meet these deadlines, policyholders may have a case for suing them under the principles of good faith and fair dealing. 

Factors That May Affect Claim Approval Timeframes 

Although California law establishes timelines, various issues can affect the time it takes an insurance company to approve a claim: 

• Completeness of Documentation: Incomplete or vague documentation could delay the insurer's decision. The insurer may also need to request additional medical records, statements from providers, or other documentation, and considerable time may be required to process anything beyond the initial submitted documents. It is your responsibility to ensure that everything is proper and complete. 
• Complexity of the Claim: If you have a claim involving specialized treatment, experimental procedures, or disputing medical necessity, additional review may elongate the approval process. 
• Insurer Practices: Some insurance companies may delay claims intentionally or request excessive documentation as a tactic to avoid paying out. These bad-faith practices are illegal, and DL Law Group has extensive experience challenging such tactics. 
• ERISA-Governed Plans: If your health insurance plan is governed by the Employee Retirement Income Security Act (ERISA), federal regulations may apply in conjunction with state laws. ERISA plans have their own timelines, typically requiring decisions within 30 days for standard claims and 72 hours for urgent claims. Our attorneys at DL Law Group are well-versed in ERISA litigation and can help navigate these complexities. 

What to Do If Your Claim Is Delayed or Denied 

If your health insurance claim is over the legally required time frame or if it has been denied, it does not mean that you are out of options: 

• Follow Up with the Insurer: Contact the insurance company to inquire about the status of your claim. Keep detailed records of all communications, including dates, times, and the names of representatives you speak with. 
• File an Appeal: If your claim is denied, file an appeal with the insurer. California law requires the insurer to include explicit instructions for filing an appeal. If you have additional documentation that supports your claim, include it in your appeal. 
• Contact the DMHC or Department of Insurance: If the insurer fails to comply with California regulations, you can file a complaint with the DMHC (for HMOs and certain PPOs) or the California Department of Insurance (for other plans). These agencies can investigate and enforce compliance. 
• Seek Legal Assistance: If your claim is unreasonably delayed, denied, or underpaid, you may be entitled to pursue legal action. DL Law Group has over 80 years of combined experience fighting insurance companies in San Francisco and across the United States. We’ve recovered millions for our clients and are prepared to bring that same firepower to your case. 

Why Choose DL Law Group? 

At DL Law Group, we know how annoying and financially stressful it can be when a health insurer doesn't approve or delays your claim for health insurance benefits. Our boutique firm offers personalized, hands-on representation, providing individual attention to your case. Here are the reasons policyholders in San Francisco come to us: 

• Proven Expertise: Our attorneys possess decades of experience in handling complex insurance claims, including health insurance disputes, ERISA litigation, and cases involving bad faith practices. 
• Track Record of Success: We’ve secured significant verdicts and settlements, including landmark cases that have set precedents in insurance law. 
• Client-Centered Approach: We treat every client as an individual, not a case number, and fight with fierce compassion to protect your rights. 
• Free Consultations: We offer FREE case evaluations with no upfront fees unless we win your case. 

Contact Us Today 

If you’re facing delays or denials with your health insurance claim in San Francisco, don’t let the insurance company take advantage of you. Contact DL Law Group for a free consultation. Our experienced attorneys will analyze the nature of your case and will explain your rights while fighting for the benefits that you deserve. Call us today or, if you're in the San Francisco area, visit our office to schedule a consultation.