Having insurance brings peace of mind. You don’t need to worry about getting sick or being injured. Until that is, the insurance company denies your claims. At that point, your peace of mind can quickly become a nightmare.
6 Reasons Health Insurance Companies Deny Claims
If your health claims are denied, your first step is to try to understand the reason for the denial. Here are the most common reasons an insurer denies a health care claim:
- The procedure or drug is considered experimental or “medically necessary”
- The cost of the treatment is greater than the limits of the policy
- The treatment, drug or procedure was not pre-authorized
- The treatment or procedure was specifically not covered by the policy
- The claim was from a provider not covered by the policy, often called a “non-network” provider
- The claim was not submitted in a timely way
Your doctor, hospital or the insurance company itself should be able to explain the reasoning behind the denial. Be sure to ask for their reasoning in writing.
Remember, however, explaining a denial does not mean the action was correct. Once you know why the insurer denied your claim, you can develop a strategy for appealing the denial. All insurance contracts include options for appealing negative decisions.
Appealing a Health Insurance Claim Denial
Sometimes, a denied health insurance claim is simply the result of a filing error by the provider. Asking the doctor, clinic, or hospital to correct and refile the claim may take care of the problem. In most cases, you should be prepared for a fight.
Here are the three main steps to pursuing an appeal of denied insurance benefits:
- Send the company notice (writing a letter or using company-approved forms) of your intent to appeal. That should be sent within 180 days after your claim was denied. Give the company information about the claim you are appealing and why you think the denial was incorrect. Keep copies of everything related to the claim and appeal, including the explanation of benefits (EOB). If you have a phone conversation related to your claim, record the other person’s name and title. Take notes during the conversation.
- If the company denies your appeal, you have the right to have your claim reviewed by a third party known as an IRO (Independent Review Organization). The insurance company must pay for the review and abide by the decision of the IRO. You must receive a determination within 20 days (five days for emergencies).
- Consider filing a bad faith insurance lawsuit against the insurance company. Consult a lawyer with experience in bad faith insurance claims to determine whether you have a case. An insurance company may be guilty of bad faith if it refused to accept evidence from you or your provider, substituted its own evidence, failed to investigate, or delayed its decision. Be sure to bring all the paperwork related to your claim to your initial meeting with the attorney.
Denied by Your Health Insurance Company? Lean on a Lawyer for Help.
Contact our lawyers for help if your health insurance company wrongly denied your claim. Our experienced bad faith insurance lawyers can advise you about your rights and options.