How to challenge an adjuster who reduced your emergency room (ER) charges under Hawaii law

Short answer: Yes — you can challenge an insurance adjuster’s decision to reduce or deny ER charges. In Hawaii there are both administrative paths (complaints to the state insurance regulator) and civil options (demand letters, negotiation, or lawsuits). Acting quickly, documenting everything, and knowing which legal theories apply will improve your chances.

Detailed answer: steps to challenge the adjuster

1. Understand why the adjuster reduced the charges

Adjusters commonly reduce ER bills for reasons such as:

They say the care was not medically necessary or related to the accident.
They apply a “usual, customary, and reasonable” (UCR) rate or an internal fee schedule.
They rely on a third‑party provider contract, balance‑billing rules, or a coding/billing error.
They claim duplicate charges, experimental treatments, or out‑of‑network rates.

2. Gather the documents you need

Documentation is critical. Collect:

Itemized ER bill (item by item).
Medical records and physician notes showing why you went to the ER and the treatment provided.
All insurer correspondence, Explanation of Benefits (EOB), and the adjuster’s written reasons for reduction.
Any provider agreements or assignment of benefits you signed.

3. Ask the provider for support

Providers can often help. Ask the ER/hospital to:

Issue an itemized, corrected bill if there was a billing or coding error.
Provide a statement linking the ER visit and treatment to the injury or event.
Explain whether they accept assignment of the claim or will place a lien on a recovery.

4. Send a written dispute to the adjuster

Write a concise dispute letter that includes:

Why you dispute the denial/reduction (refer to medical records and bills).
Copies of the supporting documents.
A deadline for response (for example, 10–14 days) and a clear request (pay the full bill, re‑evaluate, or explain the basis for reduction).

Send by certified mail or another method that gives proof of delivery.

5. Use the state regulator if the insurer won’t fix it

Hawaii regulates insurers and can accept complaints about unfair claims handling. The Department of Commerce and Consumer Affairs (DCCA) Insurance Division handles consumer complaints and can investigate whether the adjuster violated Hawaii’s insurance laws or unfair claims practices. File a complaint online or by mail. See the Insurance Division’s consumer pages: https://cca.hawaii.gov/ins/consumer/. For general insurance law reference, see Hawaii Revised Statutes, chapter 431: https://www.capitol.hawaii.gov/hrscurrent/Vol10_Ch0431-0486/HRS0431/.

6. Consider alternative dispute paths and court options

If negotiation and regulatory complaints fail, consider:

Demand letter from your attorney to the insurer or adjuster demanding payment or re‑evaluation.
Mediation or arbitration if your claim or policy requires it.
Filing a lawsuit for breach of contract (if you have an insured‑contract theory), or for bad faith or unfair claim practices in some cases. Note: statutory and case law limits may apply.
Small claims court for smaller disputes (Hawaii’s small claims procedures are available through the Hawaii State Judiciary: https://www.courts.state.hi.us/self-help/small_claims/).

7. When to hire an attorney

Hire a personal injury or insurance‑claims attorney if:

The disputed amount is large.
The insurer’s position is complex or relies on legal arguments.
The insurer appears to be acting in bad faith or refuses to negotiate.
You need help preserving rights against a provider’s lien or handling settlement distribution.

An attorney can draft demand letters, negotiate settlements, and file suit if needed.

What outcomes to expect

Possible results include:

Insurer pays the full ER charges after review.
Insurer pays a negotiated portion and you or the provider accept a reduced amount.
Provider pursues a lien or balance against a recovery from the at‑fault party.
DCCA investigation that leads to insurer corrective action or report, though regulators do not guarantee payment.
Court judgment in your favor (less common unless law clearly supports your position).

Practical timeline and tips

Act quickly: disputes are easier to resolve when records are fresh and medical providers cooperate.
Keep copies of every communication and send important letters certified mail.
Be specific in your dispute: identify the line items being disputed and attach supporting records.
Stay professional in all communications. Escalate to a supervisor or file a regulator complaint if necessary.

Relevant Hawaii resources

Hawaii DCCA Insurance Division — consumer information and complaints: https://cca.hawaii.gov/ins/consumer/
Hawaii Revised Statutes (insurance chapter): https://www.capitol.hawaii.gov/hrscurrent/Vol10_Ch0431-0486/HRS0431/
Hawaii State Judiciary — small claims self‑help: https://www.courts.state.hi.us/self-help/small_claims/

Helpful Hints

Request an itemized bill immediately. The exact line items make disputes easier to win.
Get a treating doctor’s note linking the ER visit to the accident or injury.
Compare the insurer’s payment rationale to the EOB and ask for the legal or policy basis for any reduction.
Preserve a paper trail: date, time, name of adjuster, and summary of each phone call.
Use the DCCA complaint process if the insurer refuses to explain reductions or re‑evaluate in good faith.
If a provider threatens to sue you for unpaid balance, inform your attorney and consider negotiating a reduced payment or payment plan while you pursue the insurer.

Disclaimer: This article is for general information only and does not constitute legal advice. It explains basic legal options under Hawaii law but does not create an attorney‑client relationship. For advice about your specific situation, consult a licensed attorney in Hawaii.