How Insurers Deny Legitimate Health Insurance Claims

By Scott Glovsky on August 16th, 2018 in Insurance and Healthcare Denials

Health insurance companies often try to make money by paying out as little as possible in claims. In many cases, this leads to the denial of legitimate health insurance claims for procedures covered by the policy, which in turn can lead to prolonged suffering or financial devastation. When insurers deny legitimate health insurance claims, they are often acting in bad faith, so it is important to know how to recognize the common excuses insurers give for denying legitimate health insurance claims.

Common Reasons Given for Denying Legitimate Claims

The Los Angeles Times reports that many insurance denials result from largely trivial bureaucratic issues, and when these denials were challenged by patients, approximately half of them were then covered. The question is: why? Is this a deliberate strategy on the part of insurance companies to see what they can get away with by wearing patients down, often while they are still sick or injured?

The most common reasons an insurer may cite when denying a legitimate claim include:

• The insured’s policy does not cover the treatment
• The insured is requesting an experimental or cosmetic treatment
• A lack of pre-authorization or referral
• The insurer does not consider the procedure to be medically necessary

Post Claim Underwriting

Although illegal, home, car, or business insurance companies may try another tactic, known as post-claim underwriting. This basically involves searching for any reason to deny a claim, such as a minor mistake in the original insurance application. They then attempt to rescind the policy, leaving the claimant uncovered.

Fighting Insurance Claim Denials

Some denials are relatively easy to fight, such as those stating the doctor used the wrong code. Other reasons for rejection can take a lot of time and effort to overturn. The Wall Street Journal recommends asking an insurance company representative for the documents needed to determine why the claim was rejected, as well as the insurance company’s appeals process. Get a copy of the plan’s Evidence of Coverage, and the guidelines used by the company to decide whether or not a procedure is considered medically necessary. Take notes and get the names of every insurance company representative with whom you speak.

If coverage was rejected under the guise of a procedure being experimental or not medically necessary, patients can have their physician write a letter to the company on their behalf. They can also look for scientific, peer-reviewed articles online that demonstrate the treatment they received benefits patients with their condition.

Contacting an Insurance Denial Attorney

If your health insurer has denied a legitimate medical claim, you may need the services of an experienced insurance attorney. Call today to make an appointment and let a seasoned lawyer review your case and advise you of your options.