Who is Eligible for Insurance Coverage in California?

Los Angeles has several types of insurance available, one of which is health insurance. Common examples of health insurance policies and health plans include health maintenance organizations (HMOs) and preferred provider organizations (PPOs). There are other forms of health insurance as well. Other kinds of insurance include homeowner’s insurance, disability insurance, life insurance, and property insurance. When one buys insurance, they buy something they hope they will never need. A person does not buy homeowner’s insurance, hoping their home will burn down. They are buying trust and peace of mind. For questions regarding Los Angeles insurance coverage eligibility, contact an experienced health insurance denial attorney. 

Health Insurance Approval Process

When individuals purchase health insurance through the California exchange known as Covered California to obtain Obamacare, the process is standardized. If the applicant qualifies for Medi-Cal, they are funneled into the Medi-Cal program. When the applicant does not qualify for Medi-Cal, they proceed through the standard application process during open enrollment between November or December and January or February each year. Once an applicant applies, they can be covered as early as the month following the application.

Who is Eligible for Insurance Coverage?

Anyone can apply for insurance coverage. Health insurance has specific requirements regarding who is eligible under the health insurance plans that the health insurance companies must follow. Health insurance companies cannot refuse to offer insurance under Obamacare for certain individuals based on pre-existing conditions or pre-existing disabilities. California law mandates that insurance companies must provide coverage for certain medical treatments. Other than the state and federal required covered healthcare services, insurance companies are generally free to determine coverage within their plans.

One requirement of Los Angeles insurance coverage eligibility for individuals is that they have an insurable interest. This applies primarily to life insurance and property insurance. Applicants cannot obtain life insurance on someone they have no real interest in. For example, they are not related to the person and not in business with them.

Insurance Company’s Duty to the Insured

In Los Angeles and the State of California, insurance companies have special duties to their policyholders. There is a special relationship between an insurance company and its policyholder. The special relationship stems from the unequal bargaining power between an insurance company and a policyholder.

An insurance company must deal fairly and in good faith with its members. When a claim is submitted, the insurance company has an obligation to give the member’s interests at least as much consideration as it gives to its own interests. The insurance company cannot put its profits over the interests of its policyholders. The special duties include that the company must perform a full, fair, and thorough investigation.

An insurance company must diligently search for evidence to support covering the claim or medical treatment. The company should perform an objective investigation. It cannot look for a way to deny the claim. The investigation must be unbiased and the company should set up systems to ensure that requests for treatment or claims are handled in good faith. This concept is referred to as the implied covenant of good faith and fair dealing. It is called the duty of good faith. If you have any questions regarding Los Angeles insurance coverage eligibility, call a lawyer today.