Health Insurance Claim Denial Reasons

September 8, 2022

Health insurance claim denial reasons vary on the situation and the language of your policy. Reasons a health insurance claim are denied may be legitimate. The company could also fail in its duty and avoid paying for a treatment covered by the policy. These denials may be for a small amount of money for a simple procedure or a costly, possibly life-saving treatment.

If you think your claim denial was a mistake, or if you believe your insurance company mistreats you, get legal advice from an experienced insurance lawyer. When your insurance claim is denied, attorney Doug Terry is here to help represent you and your best interests.

Why Do Health Insurance Claims Get Denied?

Paperwork Errors or Insufficient Information

There may be typographical errors, or the insurance company may have the wrong records or information. The company won’t make a coverage decision if it doesn’t have enough information or documentation. A provider may have used the incorrect billing code. Ideally, this could be cleared up easily and quickly

Not Medically Necessary

The policy doesn’t cover medical treatment, like cosmetic surgery, unless it’s medically necessary. The insurer claims the procedure is not needed, so it won’t pay for it. You may be able to get the company to change its position with additional information or records. Your physician may need to contact the company to better explain your situation.

Cost Control

Reasons a health insurance claim is denied can include limiting how much the company spends. The insurer may believe you deserve treatment but wants you to try another, less costly option first. It may be a different drug or a course of physical therapy instead of surgery. Talk to your doctor about whether this is worth trying or if the company should be convinced your plan is needed.

This cheaper alternative may be low risk. Your need for addressing your condition may not be urgent, so it may be worth a try. But if time is critical and your physician believes the insurer’s suggested treatment won’t work, it may be worth fighting for.

What You Want Isn’t Covered by Your Plan

Perhaps your requested treatment isn’t a covered benefit. It may not have Food and Drug Administration approval. You may have a policy that doesn’t comply with the Affordable Care Act (“Obamacare”) so many services may not be covered.

Your carrier won’t pay for experimental treatments or those it feels are not sufficiently proven to be safe and effective. With enough documentation and input from your physician, you may be able to turn the tide. It may be covered if you or your physician can show that it’s:

• Medically necessary
• Considered standard treatment by the medical community
• The only treatment that may work (you’ve unsuccessfully tried others)
• Less expensive than the standard treatment.

If you’re in a clinical trial, those organizing it should pay for your related medical appointments and treatment.

Provider Network Issues

Your policy may cover treatment only by those in its provider network. It may allow coverage outside the network with pre-approval, which you may not have gotten. If what you need isn’t available in-network, the company should make an exception.

If your preferred, out-of-network healthcare provider agrees to be paid the insurance company’s in-network rate, the carrier may agree to your request. If this is the case, your provider may bill you the difference between what it normally charges and what your insurer will pay. Try to get them to agree ahead of time that you won’t get stuck with these bills, which could be substantial.

Right Treatment, Wrong Place

Your carrier may not have a problem paying for treatment but wants you to have it done at a particular medical practice or hospital. You may want to be admitted to a hospital, but the carrier wants the procedure done on an outpatient basis.

You or Your Healthcare Provider Didn’t Follow Your Health Plan’s Rules

Reasons a health insurance claim is denied could include your breaking one of the many rules you need to obey. A significant problem may be getting pre-authorization from the insurer before a procedure, test, or scan. It’s a tripwire for unaware patients. Not getting pre-authorization is a simple way for the insurance company to deny coverage and save money.

Look up your coverage or call your carrier and find out everything that requires pre-authorization. You may think it’s just to see a specialist, but it also may include tests, X-rays, MRIs, and CT scans. Without their prior okay, the company will probably not pay for it. If you learn this is a problem before your insurer’s official denial, your physician may be able to backdate its authorization request.

Lack of Payment

Your coverage may be denied because a premium wasn’t paid. If you made a good-faith mistake or it was caused by something out of your control (e.g., your employer made an error), explain your situation as best you can. If your employer or payroll service caused the problem, a letter from them or a conference call between the three of you could help.

Reasons a Health Insurance Claim is Denied Should Not Include Avoiding Coverage You Paid For

Why do health insurance claims get denied? Sometimes for good reasons and sometimes just to save money, no matter how it impacts you. If you believe your health insurance claim denial reasons violate your rights, get legal advice from Doug Terry. Our firm works tirelessly for those who were wronged by their insurance companies.

A coverage denial may just be the first step in the process. There can also be an internal appeal, an external review, and possibly a bad faith lawsuit. We’ll start with a case evaluation so we can learn more about your case. A health insurance claim denial attorney can give you suggestions and possible next steps. If you choose to retain our services, we can start working on your case and put our experience to work for you. Contact our office today by calling (405) 463-6362 to schedule your case evaluation.