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What are Common Reasons for Health Insurance Disputes?

When health insurers deny claims for surgery or other treatment, the most common reasons they give are that the treatment is not medically necessary or the procedure is experimental or investigational. Your doctor may have a different opinion than the insurance company, and an experienced California insurance law attorney can help you prove your case and get coverage for your medical care, along with compensation for any harm caused by a wrongful denial of coverage.

Claim Denials Based on Medical Necessity

Would your doctor prescribe a procedure or treatment if the doctor didn’t feel it wasn’t medically necessary? Most patients would say no, but insurance companies take a harder look before they cover certain procedures. Insurance companies use very narrow definitions to determine medical necessity. These definitions even include a cost element: they’ll say a treatment that costs more than another method that could give a similar result is not “medically necessary,” even though your doctor might have excellent reasons for recommending one course of treatment over another. An insurer’s blanket denial without evaluating the individual patient’s needs is arguably not a good faith insurance practice.

Insurance company interpretations of medical necessity have led them to deny coverage of prostheses built with microprocessors, preferring traditional prosthetics instead, despite the fact that microprocessor prostheses can improve a patient’s gait and prevent more falls and injuries. Medical necessity has also been behind denials of reconstructive surgery, removal of excess skin after bariatric surgery, and tumescent liposuction for lipedema. California law requires insurers to cover reconstructive surgery to restore a patient’s normal appearance. However, insurers still attempt to deny coverage of procedures that could lead to a functional improvement or better quality of life. If you don’t know your rights, you might take the carrier’s word for it and skip getting the best care for your condition.


Another major category of insurance claim denials is that a requested procedure is experimental or investigational. They might claim, for instance, that a treatment is not approved by the FDA or that it hasn’t been widely recognized in the medical community as a safe and effective method for treating the underlying condition. This explanation sounds reasonable enough, but insurers routinely abuse this excuse and call procedures experimental even when they’ve been FDA-approved for years or are currently being performed at major medical facilities around the country with positive results. One case in point is Artificial Disc Replacement surgery, a procedure which has been approved by the FDA for more than 15 years yet is still routinely denied as experimental by insurers who would rather have you undergo spinal fusion.

Insurance Claim Denied? You Don’t Have to Take the Insurer’s Word for It.

When an insurer denies your claim for any reason, they make it sound official and point to highly technical language in their policies to back them up, but that initial denial is not the final say. You can appeal the denial through the insurer’s administrative procedures and even go to court if you need to. An experienced insurance lawyer can advise and represent you to help you challenge a denial at the earliest stages.

If you have been denied coverage because your requested procedure is allegedly not medically necessary, experimental or investigational, or based on a pre-existing condition, contact Gianelli & Morris for a free consultation with an experienced and successful California insurance law attorney.

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