Why Would a Health Insurance Claim Be Denied?
Health care insurance should provide individuals with peace of mind that medical costs will be covered when treatment becomes necessary. Unfortunately, health care insurance does not always cover expenses as expected. Insurance companies are often out to make a profit and they may do so by denying a valid health insurance claim.
Pursuing coverage for a denied claim can be complicated and frustrating. The health insurance lawyers at The Tawwater Law Firm in Oklahoma City, OK, understand the insurance claim and appeals process. Here, we discuss some of the most common reasons for a health insurance claim to be denied, and the process of appealing an insurance denial made in bad faith.
Paperwork errors are frequently the cause of insurance claim denials. The insurance company may claim they never received proper paperwork, they could cite typos or billing code errors, or they could say something on the claim is misrepresented.
Treatment Is Deemed Unnecessary
Even if a medical provider deems a medical procedure or treatment necessary, the insurance provider can determine it is unnecessary. Insurance companies work with in-house doctors to evaluate the validity of health insurance claims. In-house doctors do not meet with the insured when deciding treatment necessity. Instead, they rely on statements provided by the insured and their healthcare provider.
Treatment Not Covered by Policy
Insurance companies often deny coverage because provided treatment is not covered by the policy. In many cases, coverage is denied because the treatment is considered cosmetic or experimental. Treatment may also not be covered if it doesn’t fall within the state’s definition of essential health benefits. For example, some medical insurance providers choose not to cover chiropractic care or acupuncture because they are not considered necessary.
Provider Charged More Than Customary
Patients have no control over the amount charged for medical care. Unfortunately, insurance companies frequently use the cost of care as a reason for a claim denial. If the insurance company finds that a medical provider charged more than is customary for care, they may deny the claim altogether or pay just a portion of the claim, leaving patients to cover the rest.
Treatment Is Out of Network
Depending on how a health insurance plan is structured, patients may only have coverage for services from providers within the plan’s network. If patients seek treatment out of the network, the claim can be denied. Treatment that is out of network may be approved if the insured can demonstrate that none of the providers within the network could provide the necessary treatment.
Appealing a Bad Faith Insurance Denial
An insurance claim denial is not final. Each insurance provider has an appeals process that allows an individual to request a claim review. The process usually begins with an internal review and then can progress to an independent external review or a lawsuit. Our Oklahoma City lawyers assist clients in filing appeals paperwork and taking a case to court, if necessary, to obtain the coverage they are due.
If you have had a health insurance claim denied and believe the decision was made in bad faith, the lawyers at The Tawwater Law Firm would be happy to review your claim. To schedule an appointment at our Oklahoma City law firm, send us a message online or call (405) 607-1400 at your earliest convenience.