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Why Do Insurance Companies Deny Claims

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Insurance is a business. Regardless of whatever your insurance provider claims in their commercials or marketing materials, their number one priority is their bottom line. Unfortunately, that means that insurance companies are often looking for any reason they can find to deny a claim. Providers may have legitimate reasons to deny health insurance claims, but it is also extremely common for providers to manufacture improper reasons to deny claims. Below, we explore some of the justifications health insurance providers might put forth to explain a claim denial. Regardless of the reasons given by your health insurance provider, if your claim was denied, you have the right to fight back with the help of a dedicated Los Angeles health insurance denial attorney.

Noncovered Charges

All insurance policies include limitations on the types of issues and procedures that are covered. Your general health insurance policy likely will not cover dental surgery, for example. You may discover that your policy does not cover fertility treatments or other specialized or elective care. When deciding whether to undergo elective care, review your policy carefully. If your claim was denied and you believe that your policy does cover the type of treatment, or your insurance agent misrepresented the scope of your coverage when you bought the policy, speak with a claims denial lawyer for help.

Lack of Medical Necessity

One of the more common reasons cited by health insurance providers when denying otherwise covered claims is “lack of medical necessity.” Many health insurers require that a procedure must be medically necessary to treat an injury or illness in order to be covered. Medical necessity can be a nebulous concept, however. If two treatments are viable, but one is both more expensive and better (more effective, more likely to cure), is it strictly “necessary?” Typically, if your doctor decides that a procedure is necessary for treatment, it is unreasonable for your insurer to disagree. They may still try, and you have the right to fight back.

Even within this framework, health insurers are known to take unreasonable shortcuts. For example, a provider may decide that anything that qualifies as “cosmetic” surgery is, by definition, not medically necessary. Some conditions require treatments otherwise viewed as cosmetic, however. For example, lipedema is a painful and debilitating condition that requires liposuction for treatment. Some insurers try to deny liposuction under their blanket “no cosmetic procedures” rule, even when it is necessary to treat a condition that can leave a person disabled and in chronic pain. Speak with an insurance denial attorney if your claim was wrongfully denied as not medically necessary.

Investigational or Experimental Procedures

Insurance providers typically require treatments to be proven, accepted by government regulators, and generally blessed by the medical community in order to be covered. Treatments that are experimental, that lack FDA approval, or that have yet to be adopted by the broader community of medical professionals might not receive coverage. Unfortunately, insurers are known to refuse treatments that have been accepted for decades by the medical community, even treatments that have FDA approval. If your insurer claims your procedure is experimental, talk to a health insurance denial attorney about how you can push back and secure coverage.

Errors With the Claim Filing

Insurers are sticklers for details and may try to rely on minor technical errors in order to refuse or delay coverage. Your name, address, or other identifying information for yourself or your healthcare provider might have a typo. A customer service representative should be able to fix the problem and get your claim covered, but if they continue to refuse your claim on minor technical grounds, you may have a claim for bad faith insurance delay or denial.

More serious difficulties may arise when more significant errors occurred. Claims must be filed within a specific time period, for example, and according to certain procedures. Your doctor (and you) must provide the insurance company with sufficient information documenting your medical issue and the proposed or given course of treatment. If information is filed late, misfiled, or lacking, your claim could be denied or delayed. Some of these issues may be resolvable by working with your doctor to get the right information submitted to the insurer, while others might require a proper appeal of your denial with the help of an insurance denial attorney.

Get Help Challenging a Health Insurance Claim Denial

If your health insurance claim has been unreasonably denied or you are dealing with other bad faith insurance issues in California, fight for the coverage you deserve with the help of the professional and effective Los Angeles insurance claim denial lawyers at Gianelli & Morris for a free consultation at 213-489-1600.

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