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Understanding your options if a health insurance claim was denied

In the unfortunate event you or a loved one are involved in a serious accident or diagnosed with a major illness, your foremost concern is always securing the best medical care possible. Indeed, you probably derive considerable comfort from believing that your health insurance will help defray some of the inevitably enormous medical expenses.

What happens, however, if this proves to be a mistaken belief? In other words, what if your insurance company, whose policy you thought you could rely on, denies coverage for a major medical event?

As frightening as this scenario can be, those who find themselves in this situation need to understand that they are not powerless and don't have to resign themselves to financial ruin.

Step one: Find out why

The first step that those who find themselves in this unenviable position should consider taking, say experts, is to determine why exactly the insurance company denied their claim so that they can take the appropriate response.

Some of the reasons why insurers will initially deny claims include:

  • The procedures/services were not covered by the policy
  • The procedures/services were not considered medically necessary
  • The procedures/services were not in-network
  • The necessary pre-authorization/referral was not secured
  • The claim failed to contain the necessary documentation
  • The claim was not submitted in a timely fashion
  • The claim contained typographical errors

As you can see, several of these issues could conceivably be corrected by making a few phone calls to the hospital or office of the medical provider, and asking them to correct or submit certain documents.

If the matter can't be resolved so neatly, insured parties still have the option of appealing the decision to deny coverage via a letter. This letter should outline why the grounds for denial were incorrect and supply the necessary evidence/documentation.

Even if this proves unsuccessful, experts urge people not to despair, as there is always the possibility of pursuing legal action. Specifically, pursuing a lawsuit accusing the insurance company of acting in bad faith.

We'll continue examining this topic in our next post ...

If you have questions or concerns relating to the denial of an insurance claim -- health, life, disability, home or auto -- consider speaking with a skilled legal professional to learn more about your options.

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