Health Insurance Coverage Denials

Although having private health insurance coverage is definitely a positive factor, even private health insurance policies have coverage limits and exclusions.  As a result, there undoubtedly will be times when you receive a notice of denial of your claim, either in full or in part.  If a private insurance company determines that your policy does not provide coverage for a particular service related to your healthcare needs, it is up to you to persuade your insurance company otherwise.  Fortunately, all insurance policies contain appeal procedures for situations in which your claim is denied.  By following these procedures closely, you can ensure that your health insurance company provides you with all benefits to which you are entitled.

Reaons for Denials

There are a number of common situations in which your health insurance company might deny your claim.  For instance, your insurance policy may require that you get prior authorization for surgery or a hospital stay.  Likewise, most insurance policies contain deductible expenses that you must pay prior to receiving any amount of coverage.  In these situations, your insurance company would be justified in denying your claim, and appealing the denial of your claim generally would not be effective or successful.

Appealing a Denial

In other cases, however, you should not simply accept the denial of your claim by your health insurance company.  For instance, if you submit a claim for a medical service that your primary physician deems to be medically necessary, and your insurance company denies coverage of the claim, an appeal is worthwhile.  While you must be organized and knowledgeable when appealing your claim, it is not as difficult, time-consuming, or costly as formal litigation through the court system.  Plus, most insurance policies require that you undergo an informal appeal before you become eligible to challenge the denial of your claim in court.

Appeals Process

• Your first step in appealing your claim should be to contact your insurance company in writing.  Your insurance policy will outline the necessary steps to appeal the denial of your claim, as well as any relevant timeframes.  Your appeal letter should be a detailed account of your medical history and diagnoses, the treatment recommended by your physician, and the medical procedures, supplies, and/or services that were denied. 
• Next, you should include any supporting information that you wish your insurance company to review in your appeal, such as medical records and statements of support from your medical providers.  You should also detail the repercussions to your state of overall health if the insurance company continues to deny your claim. 
• Finally, whenever you have contact with your insurance company regarding the denial of your claim, whether by telephone or in writing, you should keep detailed records as to the name of the representative that you contacted, or who contacted you, the substance of the contact, and the date and time on which the contact occurred.

Getting Help for Denials

For further assistance in dealing with your health insurance company, medicare denials, and medicaid denials, filing an insurance claim for an accident, and appealing the denial of your claims, you can always contact your state department of insurance.  All states have insurance departments that may be able to provide you with additional information about your rights and responsibilities as an insurance policyholder, as well as appeal and grievance procedures.  Furthermore, you should consult with an attorney who is experienced in healthcare law to assist you in evaluating your claim, particularly if you have experienced multiple denials of your claim at an administrative level.  If your only remaining remedy is to file a lawsuit against your health insurance company, then you will need the assistance of an experienced attorney to guide you through the litigation process.