Understanding Denied Health Insurance Claims

The Mayer, Graff & Wallace team explain what you should do when your health insurance claim is denied.

Individuals who purchase health insurance for personal and family coverage rely on the health insurance to be there when medical treatment is needed, whether for a routine check-up or a serious medical condition. However, there are times when the health insurance company makes a bad situation worse and fails to pay for treatment that it is contractually obligated to pay for. In fact, according to the AARP, 200 million claims are denied annually.

Some denials are easier to fix, such as denials for incorrect billing codes and missing claim information. Patients can usually work with their medical provider’s billing office to correct these mistakes. Other denials can be more complicated, such as denials because of network issues or because a treatment was considered experimental or not medically necessary. In these situations, individuals may need to review the insurance policy language, or find doctors and professionals who will support the treatment.

What should you do if your claim is denied? Keep a record of all paperwork you’re sent. You can request that the insurance company provide the reason for denial in a written letter. You have a right to an internal review of your claim through the insurance company, and the insurance company must respond to you within certain time limits. In some situations, you also have a right to an external review of your claim by an outside third party. Importantly, you should keep track of the time limits for requesting additional reviews, which your insurer must provide to you.

Don’t give in to the insurance company’s denial—they see a denial as a way of getting you to walk away (and pay out-of-pocket, saving them the cost of your treatment). If your health insurance claim has been denied, contact the MGW lawyers for a free consultation. We understand health insurance policies and can identify what steps need to be taken to improve the chances of reversing a denial. We also have the skill and experience to go after the insurance company if formal legal action is required.